- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,081.45 / $4,344.84 / $7,518.74
| Facility | | $3,081.45 | $4,344.84 | $7,518.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,501.42 / $3,008.95 / $3,081.45
| Professional | | $2,501.42 | $3,008.95 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,934.73 / $3,452.62 / $3,797.88
| Facility | | $2,934.73 | $3,452.62 | $3,797.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,008.95 / $6,294.22 / $13,785.00
| Facility | | $3,008.95 | $6,294.22 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,081.45 / $3,081.45 / $3,081.45
| Professional | | $3,081.45 | $3,081.45 | $3,081.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.04 / $3,021.04 / $3,625.24
| Professional | | $3,021.04 | $3,021.04 | $3,625.24 |