- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.91 / $4,837.60 / $8,094.15
| Facility | | $2,886.91 | $4,837.60 | $8,094.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,778.99 / $3,705.23
| Professional | | $2,698.05 | $2,778.99 | $3,705.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,315.77 / $8,490.76 / $14,430.13
| Facility | | $2,315.77 | $8,490.76 | $14,430.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,590.13 / $2,611.71 / $2,872.88
| Professional | | $2,590.13 | $2,611.71 | $2,872.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,545.33 / $2,698.05 / $2,698.05
| Facility | | $2,545.33 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Professional | | $2,698.05 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,698.05 / $3,106.53 / $5,385.45
| Facility | | $2,698.05 | $3,106.53 | $5,385.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $5,854.77
| Professional | | $2,698.05 | $2,698.05 | $5,854.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $3,003.50
| Professional | | $2,698.05 | $2,698.05 | $3,003.50 |