- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,677.35 / $9,120.11
| Facility | | $2,884.03 | $4,677.35 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $3,630.78
| Professional | | $2,884.03 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,981.07 / $8,317.64
| Facility | | $2,884.03 | $3,981.07 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,019.95 / $4,365.16
| Professional | | $2,187.76 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $5,888.44
| Facility | | $3,090.30 | $3,090.30 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,019.95 / $3,090.30
| Professional | | $2,344.23 | $3,019.95 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $4,570.88
| Facility | | $2,754.23 | $2,884.03 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,630.78
| Professional | | $3,019.95 | $3,019.95 | $3,630.78 |