- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,511.89 / $8,511.38
| Facility | | $2,398.83 | $2,511.89 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,511.89 / $3,548.13
| Professional | | $1,905.46 | $2,511.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,128.61 / $6,165.95
| Professional | | $4,168.69 | $5,128.61 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,570.88 / $7,244.36
| Professional | | $3,090.30 | $4,570.88 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,890.45 / $7,244.36
| Facility | | $2,398.83 | $3,890.45 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,466.84 / $5,248.07
| Professional | | $2,290.87 | $4,466.84 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $2,041.74
| Facility | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,466.84 / $6,025.60
| Professional | | $2,290.87 | $4,466.84 | $6,025.60 |