- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,543.89 / $3,307.06 / $5,543.14
| Facility | | $2,543.89 | $3,307.06 | $5,543.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,543.89 / $2,608.16 / $3,078.11
| Professional | | $2,543.89 | $2,608.16 | $3,078.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,543.89 / $2,759.89 / $3,119.87
| Professional | | $2,543.89 | $2,759.89 | $3,119.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,608.16 / $2,608.16 / $2,732.53
| Facility | | $2,608.16 | $2,608.16 | $2,732.53 |
- 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
- $3,469.35 / $3,556.16 / $13,367.15
| Facility | | $3,469.35 | $3,556.16 | $13,367.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,064.38 / $12,064.38 / $12,064.38
| Professional | | $12,064.38 | $12,064.38 | $12,064.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.43 / $4,411.16 / $5,747.87
| Facility | | $2,673.43 | $4,411.16 | $5,747.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,529.92 / $2,608.16 / $3,077.63
| Professional | | $2,529.92 | $2,608.16 | $3,077.63 |