- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,892.01 / $1,892.01 / $3,975.58
| Facility | | $1,892.01 | $1,892.01 | $3,975.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,509.56 / $1,892.01 / $1,967.69
| Professional | | $1,509.56 | $1,892.01 | $1,967.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,140.71 / $3,558.14 / $3,975.58
| Facility | | $3,140.71 | $3,558.14 | $3,975.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,844.39 / $1,876.10 / $2,589.01
| Professional | | $1,844.39 | $1,876.10 | $2,589.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,961.73 / $4,355.49 / $5,565.81
| Facility | | $2,961.73 | $4,355.49 | $5,565.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,379.24 / $4,373.14 / $5,367.03
| Professional | | $3,379.24 | $4,373.14 | $5,367.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,571.77 / $2,571.77 / $3,975.58
| Facility | | $2,571.77 | $2,571.77 | $3,975.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,877.39 / $2,571.77 / $3,670.96
| Professional | | $1,877.39 | $2,571.77 | $3,670.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.36 / $1,983.38 / $2,629.16
| Professional | | $1,021.36 | $1,983.38 | $2,629.16 |