- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,344.23 / $8,511.38
| Facility | | $2,290.87 | $2,344.23 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,344.23 / $3,801.89
| Professional | | $1,513.56 | $2,344.23 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,897.79 / $5,888.44
| Professional | | $4,073.80 | $4,897.79 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,981.07 / $6,606.93
| Professional | | $3,162.28 | $3,981.07 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,090.30 / $6,760.83
| Facility | | $2,290.87 | $3,090.30 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,168.69 / $5,370.32
| Professional | | $2,398.83 | $4,168.69 | $5,370.32 |
- 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
- $2,398.83 / $4,265.80 / $5,623.41
| Professional | | $2,398.83 | $4,265.80 | $5,623.41 |