- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,617.46 / $3,617.46 / $4,995.54
| Facility | | $3,617.46 | $3,617.46 | $4,995.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,276.07 / $2,784.87 / $3,617.46
| Professional | | $1,276.07 | $2,784.87 | $3,617.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,272.94 / $3,272.94 / $3,272.94
| Facility | | $3,272.94 | $3,272.94 | $3,272.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,928.42 / $4,306.50 / $4,306.50
| Professional | | $2,928.42 | $4,306.50 | $4,306.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,866.15 / $2,972.18 / $4,292.14
| Facility | | $1,866.15 | $2,972.18 | $4,292.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,469.12 / $2,878.91 / $4,315.72
| Professional | | $2,469.12 | $2,878.91 | $4,315.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,583.90 / $2,583.90 / $2,583.90
| Facility | | $2,583.90 | $2,583.90 | $2,583.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.40 / $1,276.07 / $2,126.78
| Professional | | $1,148.40 | $1,276.07 | $2,126.78 |