- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $3,630.78
| Facility | | $2,290.87 | $2,290.87 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,290.87 / $3,890.45
| Professional | | $1,778.28 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,162.28
| Professional | | $3,090.30 | $3,090.30 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Facility | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,570.40
| Professional | | $1,862.09 | $1,862.09 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,311.31 / $5,495.41
| Facility | | $2,691.53 | $3,311.31 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $3,162.28
| Professional | | $1,348.96 | $1,995.26 | $3,162.28 |