- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,754.23 / $8,511.38
| Facility | | $2,511.89 | $2,754.23 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,754.23 / $3,235.94
| Professional | | $2,511.89 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Professional | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,630.78 / $7,413.10
| Facility | | $2,511.89 | $3,630.78 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,265.80 / $5,370.32
| Professional | | $2,344.23 | $4,265.80 | $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
- $2,344.23 / $4,073.80 / $5,495.41
| Professional | | $2,344.23 | $4,073.80 | $5,495.41 |