- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $5,888.44
| Facility | | $2,290.87 | $3,019.95 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,454.71 / $3,019.95
| Professional | | $2,187.76 | $2,454.71 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $6,456.54 / $7,413.10
| Professional | | $4,786.30 | $6,456.54 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,677.35
| Professional | | $3,715.35 | $3,715.35 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,454.71 / $5,888.44
| Facility | | $1,949.84 | $2,454.71 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,890.45 / $6,456.54
| Professional | | $1,348.96 | $3,890.45 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,311.31 / $5,495.41
| Professional | | $1,348.96 | $3,311.31 | $5,495.41 |