- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,818.38 / $8,511.38
| Facility | | $2,691.53 | $2,818.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,884.03 / $4,168.69
| Professional | | $2,691.53 | $2,884.03 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,309.57 / $7,413.10
| Professional | | $5,128.61 | $6,309.57 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,248.07 / $8,511.38
| Professional | | $4,073.80 | $5,248.07 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,168.69 / $8,511.38
| Facility | | $2,818.38 | $4,168.69 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,011.87 / $6,025.60
| Professional | | $2,511.89 | $5,011.87 | $6,025.60 |
- 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
- $2,511.89 / $5,011.87 / $6,918.31
| Professional | | $2,511.89 | $5,011.87 | $6,918.31 |