- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,442.73 / $2,442.73 / $6,281.33
| Facility | | $2,442.73 | $2,442.73 | $6,281.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,442.73 / $2,442.73 / $3,280.25
| Professional | | $2,442.73 | $2,442.73 | $3,280.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,252.77 / $7,031.60 / $7,851.67
| Professional | | $5,252.77 | $7,031.60 | $7,851.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,640.88 / $3,640.88 / $4,551.09
| Professional | | $3,640.88 | $3,640.88 | $4,551.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,093.78 / $2,652.12 / $6,281.33
| Facility | | $2,093.78 | $2,652.12 | $6,281.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,779.71 / $4,187.56 / $6,979.26
| Professional | | $1,779.71 | $4,187.56 | $6,979.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $4,144.10 / $5,932.37
| Professional | | $1,465.64 | $4,144.10 | $5,932.37 |