- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,630.27 / $8,511.38
| Facility | | $2,511.89 | $2,630.27 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,630.27 / $3,715.35
| Professional | | $2,344.23 | $2,630.27 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,606.93 / $7,943.28
| Professional | | $5,370.32 | $6,606.93 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,248.07 / $8,912.51
| Professional | | $3,467.37 | $5,248.07 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,073.80 / $7,762.47
| Facility | | $2,630.27 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,786.30 / $5,623.41
| Professional | | $2,570.40 | $4,786.30 | $5,623.41 |
- 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
- $2,570.40 / $4,786.30 / $6,456.54
| Professional | | $2,570.40 | $4,786.30 | $6,456.54 |