- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,663.41 / $2,663.41 / $3,484.42
| Facility | | $2,663.41 | $2,663.41 | $3,484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,663.41 / $2,663.41 / $3,484.42
| Professional | | $2,663.41 | $2,663.41 | $3,484.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,347.25 / $4,040.98 / $4,077.23
| Professional | | $3,347.25 | $4,040.98 | $4,077.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,243.88 / $4,286.31 / $5,304.84
| Professional | | $4,243.88 | $4,286.31 | $5,304.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,812.47 / $3,169.46 / $7,990.23
| Facility | | $1,812.47 | $3,169.46 | $7,990.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.34 / $3,043.90 / $5,833.66
| Professional | | $1,826.34 | $3,043.90 | $5,833.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,430.00 / $2,737.25 / $5,477.08
| Professional | | $1,430.00 | $2,737.25 | $5,477.08 |