- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $8,511.38
| Facility | | $2,630.27 | $2,754.23 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,754.23 / $4,466.84
| Professional | | $1,778.28 | $2,754.23 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,754.40 / $6,918.31
| Professional | | $4,677.35 | $5,754.40 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,570.88 / $7,585.78
| Professional | | $3,630.78 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $7,943.28
| Facility | | $2,630.27 | $3,630.78 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,897.79 / $6,165.95
| Professional | | $1,995.26 | $4,897.79 | $6,165.95 |
- 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
- $1,995.26 / $5,011.87 / $6,606.93
| Professional | | $1,995.26 | $5,011.87 | $6,606.93 |