- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,291.38 / $2,291.38 / $2,291.38
| Facility | | $2,291.38 | $2,291.38 | $2,291.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.64 / $2,126.06 / $2,296.14
| Professional | | $2,051.64 | $2,126.06 | $2,296.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,653.72 / $4,714.47 / $5,393.84
| Facility | | $3,653.72 | $4,714.47 | $5,393.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,753.59 / $2,902.12 / $2,902.12
| Professional | | $2,753.59 | $2,902.12 | $2,902.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,886.72 / $2,886.72 / $2,886.72
| Facility | | $2,886.72 | $2,886.72 | $2,886.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,107.31 / $2,107.31 / $2,886.72
| Professional | | $2,107.31 | $2,107.31 | $2,886.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,064.41 / $3,064.41 / $3,064.41
| Facility | | $3,064.41 | $3,064.41 | $3,064.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,064.41 / $3,064.41 / $4,337.32
| Professional | | $3,064.41 | $3,064.41 | $4,337.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,441.78 / $3,441.78 / $3,441.78
| Professional | | $3,441.78 | $3,441.78 | $3,441.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.92 / $2,352.00 / $3,243.48
| Professional | | $1,794.92 | $2,352.00 | $3,243.48 |