- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,684.44 / $1,684.44 / $3,539.42
| Facility | | $1,684.44 | $1,684.44 | $3,539.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,428.06 / $1,684.44 / $1,751.81
| Professional | | $1,428.06 | $1,684.44 | $1,751.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,796.14 / $3,167.78 / $3,539.42
| Facility | | $2,796.14 | $3,167.78 | $3,539.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,732.93 / $1,748.40 / $2,399.08
| Professional | | $1,732.93 | $1,748.40 | $2,399.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,452.51 / $3,716.39 / $4,955.18
| Facility | | $2,452.51 | $3,716.39 | $4,955.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,008.51 / $3,893.36 / $4,778.22
| Professional | | $3,008.51 | $3,893.36 | $4,778.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,289.62 / $2,289.62 / $3,539.42
| Facility | | $2,289.62 | $2,289.62 | $3,539.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,671.42 / $1,671.42 / $3,630.76
| Professional | | $1,671.42 | $1,671.42 | $3,630.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.63 / $1,765.78 / $2,479.19
| Professional | | $959.63 | $1,765.78 | $2,479.19 |