- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $5,370.32 / $7,413.10
| Facility | | $2,238.72 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $3,548.13
| Professional | | $1,905.46 | $2,238.72 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,818.38 / $6,025.60
| Facility | | $1,174.90 | $2,818.38 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,511.89 / $4,168.69
| Professional | | $2,089.30 | $2,511.89 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $6,760.83
| Professional | | $1,819.70 | $2,630.27 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,388.44 / $11,748.98
| Professional | | $2,630.27 | $3,388.44 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,754.40 / $8,511.38
| Facility | | $1,513.56 | $5,754.40 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $6,025.60
| Professional | | $2,137.96 | $3,019.95 | $6,025.60 |