- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $6,760.83
| Facility | | $3,715.35 | $3,715.35 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,311.31 / $4,677.35
| Professional | | $2,570.40 | $3,311.31 | $4,677.35 |
- 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
- $2,570.40 / $2,691.53 / $2,691.53
| Professional | | $2,570.40 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,677.35 / $5,888.44
| Professional | | $2,290.87 | $4,677.35 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $9,332.54
| Facility | | $3,715.35 | $3,715.35 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $5,248.07
| Professional | | $3,162.28 | $3,890.45 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $4,677.35
| Professional | | $2,290.87 | $2,290.87 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,890.45 / $4,677.35
| Facility | | $3,467.37 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,890.45
| Professional | | $1,621.81 | $2,344.23 | $3,890.45 |