- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $8,511.38
| Facility | | $2,454.71 | $2,454.71 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,454.71 / $5,495.41
| Professional | | $2,238.72 | $2,454.71 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,248.07 / $6,309.57
| Professional | | $4,265.80 | $5,248.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,570.88 / $7,413.10
| Professional | | $2,951.21 | $4,570.88 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,090.30 / $5,370.32
| Facility | | $2,454.71 | $3,090.30 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,466.84 / $19,498.45
| Professional | | $2,570.40 | $4,466.84 | $19,498.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,888.44 / $14,125.38
| Facility | | $5,370.32 | $5,888.44 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,365.16 / $5,888.44
| Professional | | $2,570.40 | $4,365.16 | $5,888.44 |