- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.85 / $2,425.85 / $5,097.31
| Facility | | $2,425.85 | $2,425.85 | $5,097.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,092.64 / $2,425.85 / $2,522.88
| Professional | | $2,092.64 | $2,425.85 | $2,522.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,026.87 / $4,562.09 / $5,097.31
| Facility | | $4,026.87 | $4,562.09 | $5,097.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,296.10 / $2,335.56 / $3,223.07
| Professional | | $2,296.10 | $2,335.56 | $3,223.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,593.83 / $5,352.18 / $7,136.23
| Facility | | $3,593.83 | $5,352.18 | $7,136.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,332.71 / $5,607.04 / $6,881.37
| Professional | | $4,332.71 | $5,607.04 | $6,881.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,297.39 / $3,297.39 / $5,097.31
| Facility | | $3,297.39 | $3,297.39 | $5,097.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,407.09 / $3,297.39 / $4,463.39
| Professional | | $2,407.09 | $3,297.39 | $4,463.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,116.77 / $6,116.77 / $6,116.77
| Facility | | $6,116.77 | $6,116.77 | $6,116.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.50 / $2,542.98 / $3,405.88
| Professional | | $1,271.50 | $2,542.98 | $3,405.88 |