- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $8,511.38
| Facility | | $2,691.53 | $2,691.53 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,691.53 / $3,890.45
| Professional | | $2,344.23 | $2,691.53 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,888.44 / $6,918.31
| Professional | | $4,677.35 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $5,128.61 / $8,511.38
| Professional | | $3,548.13 | $5,128.61 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,981.07 / $7,943.28
| Facility | | $2,691.53 | $3,981.07 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,786.30 / $5,754.40
| Professional | | $2,511.89 | $4,786.30 | $5,754.40 |
- 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 / $4,786.30 / $6,606.93
| Professional | | $2,511.89 | $4,786.30 | $6,606.93 |