- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,630.27 / $8,511.38
| Facility | | $2,570.40 | $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 / $5,623.41 / $6,606.93
| Professional | | $4,466.84 | $5,623.41 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,365.16 / $7,413.10
| Professional | | $3,548.13 | $4,365.16 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $7,585.78
| Facility | | $2,570.40 | $3,467.37 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,677.35 / $6,025.60
| Professional | | $2,454.71 | $4,677.35 | $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
- $2,454.71 / $4,786.30 / $6,309.57
| Professional | | $2,454.71 | $4,786.30 | $6,309.57 |