- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,182.44 / $2,182.44 / $4,585.87
| Facility | | $2,182.44 | $2,182.44 | $4,585.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,182.44 / $2,226.10 / $2,444.34
| Professional | | $2,182.44 | $2,226.10 | $2,444.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,622.84 / $4,104.35 / $4,585.87
| Facility | | $3,622.84 | $4,104.35 | $4,585.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,237.00 / $2,704.43 / $3,700.21
| Professional | | $2,237.00 | $2,704.43 | $3,700.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,439.40 / $5,044.46 / $6,675.23
| Facility | | $3,439.40 | $5,044.46 | $6,675.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,897.99 / $5,044.46 / $6,190.92
| Professional | | $3,897.99 | $5,044.46 | $6,190.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,780.72 / $2,780.72 / $4,585.87
| Facility | | $2,780.72 | $2,780.72 | $4,585.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,029.93 / $2,780.72 / $4,704.22
| Professional | | $2,029.93 | $2,780.72 | $4,704.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.08 / $2,287.84 / $3,368.47
| Professional | | $1,480.08 | $2,287.84 | $3,368.47 |