- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,951.21 / $8,511.38
| Facility | | $2,818.38 | $2,951.21 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $6,606.93
| Professional | | $2,187.76 | $2,951.21 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $6,025.60 / $7,079.46
| Professional | | $4,897.79 | $6,025.60 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,248.07 / $8,511.38
| Professional | | $3,630.78 | $5,248.07 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,168.69 / $8,511.38
| Facility | | $2,818.38 | $4,168.69 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,128.61 / $6,025.60
| Professional | | $2,570.40 | $5,128.61 | $6,025.60 |
- 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
- $2,570.40 / $5,128.61 / $7,079.46
| Professional | | $2,570.40 | $5,128.61 | $7,079.46 |