- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $5,888.44
| Facility | | $2,570.40 | $3,162.28 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,235.94 / $5,370.32
| Professional | | $2,570.40 | $3,235.94 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $12,882.50
| Facility | | $2,570.40 | $3,467.37 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,715.35 / $7,244.36
| Professional | | $3,388.44 | $3,715.35 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,073.80 / $25,703.96
| Facility | | $4,073.80 | $4,073.80 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $9,120.11
| Professional | | $2,951.21 | $2,951.21 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,265.80 / $7,585.78
| Facility | | $2,754.23 | $4,265.80 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,090.30 / $4,677.35
| Professional | | $2,344.23 | $3,090.30 | $4,677.35 |