- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $5,370.32
| Facility | | $3,890.45 | $3,890.45 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,511.89 / $3,890.45
| Professional | | $1,862.09 | $2,511.89 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,786.30
| Facility | | $3,467.37 | $3,467.37 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,677.35 / $4,677.35
| Professional | | $3,162.28 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,365.16 / $5,754.40
| Facility | | $2,041.74 | $4,365.16 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,311.31 / $4,677.35
| Professional | | $2,691.53 | $3,311.31 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,090.30
| Facility | | $2,818.38 | $2,818.38 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $3,090.30
| Professional | | $1,318.26 | $1,862.09 | $3,090.30 |