- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,763.29 / $1,896.37 / $2,172.67
| Facility | | $1,763.29 | $1,896.37 | $2,172.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,763.29 / $2,172.67 / $3,074.00
| Professional | | $1,763.29 | $2,172.67 | $3,074.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,148.57 / $3,148.57 / $3,148.57
| Facility | | $3,148.57 | $3,148.57 | $3,148.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,298.46 / $2,298.46 / $3,148.57
| Professional | | $2,298.46 | $2,298.46 | $3,148.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,749.36 / $2,749.36 / $2,749.36
| Facility | | $2,749.36 | $2,749.36 | $2,749.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,302.63 / $2,878.29 / $4,130.10
| Professional | | $2,302.63 | $2,878.29 | $4,130.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,840.26 / $2,831.17 / $3,114.28
| Professional | | $1,840.26 | $2,831.17 | $3,114.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,773.60 / $2,060.46 / $3,104.50
| Professional | | $1,773.60 | $2,060.46 | $3,104.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,831.17 / $2,831.17 / $2,831.17
| Professional | | $2,831.17 | $2,831.17 | $2,831.17 |