- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,853.53 / $3,266.08 / $4,451.51
| Facility | | $2,853.53 | $3,266.08 | $4,451.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,853.53 / $3,266.08 / $3,266.08
| Professional | | $2,853.53 | $3,266.08 | $3,266.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,410.89 / $2,410.89 / $2,410.89
| Facility | | $2,410.89 | $2,410.89 | $2,410.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.35 / $2,410.89 / $2,681.63
| Professional | | $2,290.35 | $2,410.89 | $2,681.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,437.81 / $3,437.81 / $4,297.26
| Professional | | $3,437.81 | $3,437.81 | $4,297.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,939.47 / $3,266.08 / $5,243.36
| Facility | | $2,939.47 | $3,266.08 | $5,243.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,266.08 / $3,300.46 / $4,125.57
| Professional | | $3,266.08 | $3,300.46 | $4,125.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.95 / $2,062.79 / $3,437.98
| Professional | | $1,443.95 | $2,062.79 | $3,437.98 |