- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $8,511.38
| Facility | | $2,754.23 | $2,884.03 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,884.03 / $7,079.46
| Professional | | $2,630.27 | $2,884.03 | $7,079.46 |
- 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
- $3,162.28 / $5,248.07 / $8,511.38
| Professional | | $3,162.28 | $5,248.07 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,715.35 / $6,025.60
| Facility | | $2,884.03 | $3,715.35 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,248.07 / $21,379.62
| Professional | | $2,818.38 | $5,248.07 | $21,379.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,041.74 / $6,025.60
| Facility | | $1,819.70 | $2,041.74 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,248.07 / $7,079.46
| Professional | | $2,818.38 | $5,248.07 | $7,079.46 |