- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,691.53 / $4,265.80
| Professional | | $1,905.46 | $2,691.53 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,623.41 / $6,760.83
| Facility | | $4,365.16 | $5,623.41 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $2,884.03
| Professional | | $2,691.53 | $2,818.38 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,981.07 / $5,495.41
| Professional | | $3,235.94 | $3,981.07 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $2,884.03
| Facility | | $1,819.70 | $2,344.23 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,754.23 / $3,715.35
| Professional | | $2,089.30 | $2,754.23 | $3,715.35 |