- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,388.44 / $6,456.54
| Facility | | $2,511.89 | $3,388.44 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,754.23 / $3,388.44
| Professional | | $2,398.83 | $2,754.23 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,918.31 / $8,128.31
| Professional | | $4,786.30 | $6,918.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $4,168.69 / $5,128.61
| Professional | | $4,168.69 | $4,168.69 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,754.23 / $6,456.54
| Facility | | $2,137.96 | $2,754.23 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,265.80 / $7,244.36
| Professional | | $1,513.56 | $4,265.80 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,630.78 / $6,165.95
| Professional | | $1,513.56 | $3,630.78 | $6,165.95 |