- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,886.74 / $5,020.42
| Facility | | $2,510.21 | $2,886.74 | $5,020.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.96 / $2,886.74 / $2,886.74
| Professional | | $1,957.96 | $2,886.74 | $2,886.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,628.75 / $3,864.00 / $4,559.52
| Professional | | $1,628.75 | $3,864.00 | $4,559.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,631.64 / $2,039.55 / $5,433.36
| Facility | | $1,631.64 | $2,039.55 | $5,433.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,054.29 / $1,506.13
| Professional | | $1,054.29 | $1,054.29 | $1,506.13 |