- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $8,511.38
| Facility | | $2,089.30 | $2,187.76 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,187.76 / $3,548.13
| Professional | | $1,412.54 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,570.88 / $5,495.41
| Professional | | $3,715.35 | $4,570.88 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,630.78 / $6,025.60
| Professional | | $2,884.03 | $3,630.78 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $6,309.57
| Facility | | $2,089.30 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,801.89 / $4,897.79
| Professional | | $2,187.76 | $3,801.89 | $4,897.79 |
- 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
- $2,187.76 / $3,981.07 / $5,248.07
| Professional | | $2,187.76 | $3,981.07 | $5,248.07 |