- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $8,511.38
| Facility | | $2,398.83 | $2,398.83 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $3,467.37
| Professional | | $2,137.96 | $2,398.83 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,495.41 / $6,456.54
| Professional | | $4,466.84 | $5,495.41 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,570.88 / $7,943.28
| Professional | | $3,235.94 | $4,570.88 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $7,079.46
| Facility | | $2,398.83 | $3,467.37 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $4,168.69 / $5,128.61
| Professional | | $2,041.74 | $4,168.69 | $5,128.61 |
- 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
- $2,041.74 / $4,365.16 / $5,754.40
| Professional | | $2,041.74 | $4,365.16 | $5,754.40 |