- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,138.60 / $4,015.45 / $6,204.67
| Facility | | $2,138.60 | $4,015.45 | $6,204.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,457.41 / $1,690.59 / $1,943.21
| Professional | | $1,457.41 | $1,690.59 | $1,943.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,429.01 / $2,429.01 / $2,429.01
| Professional | | $2,429.01 | $2,429.01 | $2,429.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,717.80 / $3,182.99 / $4,405.96
| Facility | | $1,717.80 | $3,182.99 | $4,405.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,554.57 / $1,943.21 / $2,614.21
| Facility | | $1,554.57 | $1,943.21 | $2,614.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $816.15 / $1,165.93 / $9,677.19
| Professional | | $816.15 | $1,165.93 | $9,677.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.44 / $1,165.93 / $2,914.82
| Professional | | $874.44 | $1,165.93 | $2,914.82 |