- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.17 / $2,425.17 / $5,095.91
| Facility | | $2,425.17 | $2,425.17 | $5,095.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,130.48 / $2,425.17 / $2,522.19
| Professional | | $2,130.48 | $2,425.17 | $2,522.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,025.77 / $4,560.84 / $5,095.91
| Facility | | $4,025.77 | $4,560.84 | $5,095.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,434.85 / $3,043.56 / $4,108.80
| Professional | | $2,434.85 | $3,043.56 | $4,108.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,821.93 / $5,605.50 / $7,134.27
| Facility | | $3,821.93 | $5,605.50 | $7,134.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,331.52 / $5,605.50 / $6,879.48
| Professional | | $4,331.52 | $5,605.50 | $6,879.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $5,095.91
| Facility | | $3,001.57 | $3,001.57 | $5,095.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $3,001.57 / $5,169.77
| Professional | | $2,191.15 | $3,001.57 | $5,169.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.73 / $2,542.29 / $3,534.50
| Professional | | $1,316.73 | $2,542.29 | $3,534.50 |