- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,156.78 / $2,156.78 / $2,156.78
| Facility | | $2,156.78 | $2,156.78 | $2,156.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,931.12 / $2,001.13 / $2,161.21
| Professional | | $1,931.12 | $2,001.13 | $2,161.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,439.08 / $4,437.52 / $5,076.97
| Facility | | $3,439.08 | $4,437.52 | $5,076.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,591.81 / $2,731.58 / $2,731.58
| Professional | | $2,591.81 | $2,731.58 | $2,731.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,941.06 / $2,941.06 / $2,941.06
| Facility | | $2,941.06 | $2,941.06 | $2,941.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,146.96 / $2,146.96 / $2,146.96
| Professional | | $2,146.96 | $2,146.96 | $2,146.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.39 / $2,884.39 / $2,884.39
| Facility | | $2,884.39 | $2,884.39 | $2,884.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.39 / $2,884.39 / $4,082.52
| Professional | | $2,884.39 | $2,884.39 | $4,082.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,378.84 / $3,378.84 / $3,378.84
| Professional | | $3,378.84 | $3,378.84 | $3,378.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,689.48 / $2,213.83 / $3,100.69
| Professional | | $1,689.48 | $2,213.83 | $3,100.69 |