- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.39 / $2,229.87 / $2,554.76
| Facility | | $2,073.39 | $2,229.87 | $2,554.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.39 / $2,486.42 / $3,614.61
| Professional | | $2,073.39 | $2,486.42 | $3,614.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,370.81 / $4,370.81 / $4,370.81
| Professional | | $4,370.81 | $4,370.81 | $4,370.81 |
- 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 / $3,057.52
| Professional | | $2,107.31 | $2,107.31 | $3,057.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,817.17 / $2,645.89 / $2,645.89
| Facility | | $1,817.17 | $2,645.89 | $2,645.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,595.96 / $3,244.95 / $4,856.45
| Professional | | $2,595.96 | $3,244.95 | $4,856.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,885.16 / $3,885.16 / $3,885.16
| Professional | | $3,885.16 | $3,885.16 | $3,885.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,753.36 / $5,753.36 / $5,753.36
| Facility | | $5,753.36 | $5,753.36 | $5,753.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,085.52 / $2,422.83 / $3,243.48
| Professional | | $2,085.52 | $2,422.83 | $3,243.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,902.12 / $2,902.12 / $4,856.45
| Professional | | $2,902.12 | $2,902.12 | $4,856.45 |