- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,773.62 / $4,326.85
| Facility | | $2,773.62 | $2,773.62 | $4,326.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,496.26 / $2,773.62 / $2,773.62
| Professional | | $2,496.26 | $2,773.62 | $2,773.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,645.60 / $3,613.55 / $5,486.29
| Facility | | $2,645.60 | $3,613.55 | $5,486.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,080.21 / $2,189.69 / $2,342.98
| Professional | | $2,080.21 | $2,189.69 | $2,342.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,558.41 / $3,558.41 / $4,448.01
| Professional | | $3,558.41 | $3,558.41 | $4,448.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,773.62 / $5,096.53
| Facility | | $2,773.62 | $2,773.62 | $5,096.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.62 / $2,802.82 / $3,503.52
| Professional | | $2,773.62 | $2,802.82 | $3,503.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $2,919.60
| Professional | | $1,226.23 | $1,751.76 | $2,919.60 |