- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,755.42 / $2,755.42 / $5,789.81
| Facility | | $2,755.42 | $2,755.42 | $5,789.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,586.03 / $2,810.52 / $2,899.79
| Professional | | $2,586.03 | $2,810.52 | $2,899.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,573.95 / $5,181.88 / $5,789.81
| Facility | | $4,573.95 | $5,181.88 | $5,789.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,900.72 / $3,171.15 / $4,376.18
| Professional | | $2,900.72 | $3,171.15 | $4,376.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,342.35 / $6,368.79 / $8,105.73
| Facility | | $4,342.35 | $6,368.79 | $8,105.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,921.34 / $6,368.79 / $7,816.24
| Professional | | $4,921.34 | $6,368.79 | $7,816.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,745.37 / $3,745.37 / $5,789.81
| Facility | | $3,745.37 | $3,745.37 | $5,789.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,734.12 / $2,734.12 / $5,939.23
| Professional | | $2,734.12 | $2,734.12 | $5,939.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,734.35 / $2,888.47 / $4,008.86
| Professional | | $1,734.35 | $2,888.47 | $4,008.86 |