- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,630.27 / $8,511.38
| Facility | | $2,511.89 | $2,630.27 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $3,548.13
| Professional | | $1,949.84 | $2,511.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,630.78 / $4,365.16
| Professional | | $3,235.94 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,370.32 / $7,943.28
| Professional | | $3,801.89 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,235.94 / $4,466.84
| Facility | | $2,630.27 | $3,235.94 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $22,387.21
| Professional | | $2,570.40 | $4,570.88 | $22,387.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,128.61 / $5,128.61
| Facility | | $4,677.35 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,630.78 / $5,128.61
| Professional | | $2,511.89 | $3,630.78 | $5,128.61 |