- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,794.18 / $1,794.18 / $3,770.02
| Facility | | $1,794.18 | $1,794.18 | $3,770.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,794.18 / $1,830.06 / $1,884.57
| Professional | | $1,794.18 | $1,830.06 | $1,884.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,978.32 / $3,374.17 / $3,770.02
| Facility | | $2,978.32 | $3,374.17 | $3,770.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,888.80 / $2,060.88 / $2,844.01
| Professional | | $1,888.80 | $2,060.88 | $2,844.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,842.81 / $4,147.02 / $5,655.03
| Facility | | $2,842.81 | $4,147.02 | $5,655.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,204.52 / $4,147.02 / $5,089.53
| Professional | | $3,204.52 | $4,147.02 | $5,089.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,677.88 / $2,677.88 / $3,770.02
| Facility | | $2,677.88 | $2,677.88 | $3,770.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,954.85 / $2,677.88 / $3,867.31
| Professional | | $1,954.85 | $2,677.88 | $3,867.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.15 / $1,880.82 / $2,605.35
| Professional | | $1,127.15 | $1,880.82 | $2,605.35 |