- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,630.78 / $5,495.41
| Facility | | $2,884.03 | $3,630.78 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,090.30 / $3,630.78
| Professional | | $2,884.03 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,162.28 / $3,235.94
| Professional | | $2,398.83 | $3,162.28 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $3,019.95
| Professional | | $2,344.23 | $2,344.23 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,467.37 / $4,897.79
| Facility | | $1,659.59 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,311.31
| Professional | | $3,019.95 | $3,019.95 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,019.95 / $3,388.44
| Professional | | $2,570.40 | $3,019.95 | $3,388.44 |