- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $8,511.38
| Facility | | $2,089.30 | $2,187.76 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,187.76 / $3,235.94
| Professional | | $1,949.84 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,128.61 / $6,025.60
| Professional | | $4,073.80 | $5,128.61 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,981.07 / $7,079.46
| Professional | | $2,951.21 | $3,981.07 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,235.94 / $6,456.54
| Facility | | $2,187.76 | $3,235.94 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,981.07 / $4,677.35
| Professional | | $2,137.96 | $3,981.07 | $4,677.35 |
- 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
- $2,137.96 / $3,981.07 / $5,248.07
| Professional | | $2,137.96 | $3,981.07 | $5,248.07 |