- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $3,235.94
| Facility | | $2,691.53 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,691.53 / $5,011.87
| Professional | | $2,041.74 | $2,691.53 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,248.07 / $5,888.44
| Facility | | $4,897.79 | $5,248.07 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,884.03
| Professional | | $2,754.23 | $2,754.23 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,548.13
| Facility | | $2,884.03 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,884.03
| Professional | | $2,089.30 | $2,089.30 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $7,244.36
| Professional | | $4,168.69 | $4,168.69 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,090.30 / $3,467.37
| Facility | | $1,412.54 | $3,090.30 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,570.40 / $4,168.69
| Professional | | $1,862.09 | $2,570.40 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $6,918.31
| Facility | | $4,265.80 | $4,265.80 | $6,918.31 |