- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,696.53 / $5,087.78 / $5,316.73
| Facility | | $2,696.53 | $5,087.78 | $5,316.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $3,025.46
| Professional | | $2,608.16 | $2,608.16 | $3,025.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,868.98 / $4,579.41 / $8,346.11
| Facility | | $2,868.98 | $4,579.41 | $8,346.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,460.53 / $2,460.53 / $3,615.71
| Facility | | $2,460.53 | $2,460.53 | $3,615.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,608.16
| Professional | | $2,608.16 | $2,608.16 | $2,608.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,875.86 / $2,764.65 / $4,202.27
| Facility | | $1,875.86 | $2,764.65 | $4,202.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,842.89 / $2,868.97 / $3,912.24
| Professional | | $2,842.89 | $2,868.97 | $3,912.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,411.16 / $4,411.16 / $4,411.16
| Facility | | $4,411.16 | $4,411.16 | $4,411.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,764.65
| Professional | | $2,608.16 | $2,608.16 | $2,764.65 |