- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.19 / $2,900.19 / $11,194.70
| Facility | | $2,900.19 | $2,900.19 | $11,194.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.19 / $2,900.19 / $2,900.19
| Professional | | $2,900.19 | $2,900.19 | $2,900.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,586.42 / $5,304.34 / $9,667.33
| Facility | | $2,586.42 | $5,304.34 | $9,667.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,301.91 / $2,301.91 / $2,301.91
| Professional | | $2,301.91 | $2,301.91 | $2,301.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Facility | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,326.34 / $2,900.19 / $4,302.80
| Facility | | $1,326.34 | $2,900.19 | $4,302.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,021.04
| Professional | | $3,021.04 | $3,021.04 | $3,021.04 |