- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,467.37 / $8,511.38
| Facility | | $3,388.44 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,467.37 / $5,623.41
| Professional | | $2,290.87 | $3,467.37 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,413.10 / $8,709.64
| Professional | | $6,025.60 | $7,413.10 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,754.40 / $9,772.37
| Professional | | $4,677.35 | $5,754.40 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,570.88 / $10,232.93
| Facility | | $3,388.44 | $4,570.88 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,165.95 / $7,943.28
| Professional | | $3,630.78 | $6,165.95 | $7,943.28 |
- 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
- $3,630.78 / $6,309.57 / $8,511.38
| Professional | | $3,630.78 | $6,309.57 | $8,511.38 |