- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $5,495.41
| Facility | | $2,137.96 | $2,137.96 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,187.76 / $2,818.38
| Professional | | $2,041.74 | $2,187.76 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,888.44 / $6,918.31
| Professional | | $3,981.07 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $4,365.16
| Professional | | $3,467.37 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $5,495.41
| Facility | | $1,819.70 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,630.78 / $6,025.60
| Professional | | $1,258.93 | $3,630.78 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,090.30 / $5,128.61
| Professional | | $1,258.93 | $3,090.30 | $5,128.61 |