- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $6,606.93
| Facility | | $2,570.40 | $2,570.40 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,630.27 / $3,467.37
| Professional | | $2,454.71 | $2,630.27 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,413.10 / $8,317.64
| Professional | | $5,370.32 | $7,413.10 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,248.07
| Professional | | $4,265.80 | $4,265.80 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $6,606.93
| Facility | | $2,187.76 | $2,818.38 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,365.16 / $7,413.10
| Professional | | $1,548.82 | $4,365.16 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,715.35 / $6,309.57
| Professional | | $1,548.82 | $3,715.35 | $6,309.57 |