- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.19 / $2,900.19 / $9,048.59
| Facility | | $2,900.19 | $2,900.19 | $9,048.59 |
- 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
- $3,716.73 / $6,695.50 / $12,665.91
| Facility | | $3,716.73 | $6,695.50 | $12,665.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,910.15 / $3,063.32 / $3,063.32
| Professional | | $2,910.15 | $3,063.32 | $3,063.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,803.81 / $3,081.45 / $3,081.45
| Professional | | $1,803.81 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,900.19 / $3,625.24 / $8,069.78
| Facility | | $2,900.19 | $3,625.24 | $8,069.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.19 / $3,202.30 / $3,842.76
| Professional | | $2,900.19 | $3,202.30 | $3,842.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,205.02
| Professional | | $3,021.04 | $3,021.04 | $3,205.02 |