- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $8,511.38
| Facility | | $2,570.40 | $2,570.40 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,570.40 / $6,025.60
| Professional | | $2,238.72 | $2,570.40 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,623.41 / $6,606.93
| Professional | | $4,466.84 | $5,623.41 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,786.30 / $7,943.28
| Professional | | $3,090.30 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,630.78 / $6,165.95
| Facility | | $2,570.40 | $3,630.78 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,677.35 / $27,542.29
| Professional | | $2,691.53 | $4,677.35 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $11,481.54
| Facility | | $1,819.70 | $2,041.74 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,677.35 / $6,165.95
| Professional | | $2,691.53 | $4,677.35 | $6,165.95 |