- 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
- $1,698.24 / $2,630.27 / $4,265.80
| Professional | | $1,698.24 | $2,630.27 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,495.41 / $6,456.54
| Professional | | $4,466.84 | $5,495.41 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,365.16 / $7,244.36
| Professional | | $3,467.37 | $4,365.16 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,467.37 / $7,585.78
| Facility | | $2,511.89 | $3,467.37 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,677.35 / $5,888.44
| Professional | | $2,570.40 | $4,677.35 | $5,888.44 |
- 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 / $4,786.30 / $6,309.57
| Professional | | $2,570.40 | $4,786.30 | $6,309.57 |