- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $3,548.13
| Facility | | $1,380.38 | $1,659.59 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $1,737.80
| Professional | | $1,318.26 | $1,513.56 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,715.35 / $4,365.16
| Professional | | $2,884.03 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,818.38
| Professional | | $2,238.72 | $2,238.72 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,479.11 / $3,548.13
| Facility | | $1,174.90 | $1,479.11 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $2,290.87 / $3,548.13
| Professional | | $741.31 | $2,290.87 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,949.84 / $2,951.21
| Professional | | $741.31 | $1,949.84 | $2,951.21 |