- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,219.12 / $3,684.53 / $5,021.83
| Facility | | $3,219.12 | $3,684.53 | $5,021.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,219.12 / $3,684.53 / $3,684.53
| Professional | | $3,219.12 | $3,684.53 | $3,684.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,719.77 / $2,719.77 / $2,719.77
| Facility | | $2,719.77 | $2,719.77 | $2,719.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,583.78 / $2,719.77 / $3,025.19
| Professional | | $2,583.78 | $2,719.77 | $3,025.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,878.48 / $3,878.48 / $4,848.10
| Professional | | $3,878.48 | $3,878.48 | $4,848.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,316.08 / $3,684.53 / $5,915.13
| Facility | | $3,316.08 | $3,684.53 | $5,915.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,684.53 / $3,723.31 / $4,654.14
| Professional | | $3,684.53 | $3,723.31 | $4,654.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.95 / $2,327.07 / $3,878.45
| Professional | | $1,628.95 | $2,327.07 | $3,878.45 |