- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,159.42 / $3,633.33 / $6,318.84
| Facility | | $3,159.42 | $3,633.33 | $6,318.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,464.35 / $3,064.64 / $3,633.33
| Professional | | $2,464.35 | $3,064.64 | $3,633.33 |
- 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
- $2,049.98 / $4,235.54 / $4,997.93
| Professional | | $2,049.98 | $4,235.54 | $4,997.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,484.88 / $2,669.71 / $9,908.58
| Facility | | $2,484.88 | $2,669.71 | $9,908.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,326.96 / $1,326.96 / $1,895.65
| Professional | | $1,326.96 | $1,326.96 | $1,895.65 |