- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,442.26 / $4,585.60 / $7,085.68
| Facility | | $2,442.26 | $4,585.60 | $7,085.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,775.30 / $1,930.64 / $2,219.13
| Professional | | $1,775.30 | $1,930.64 | $2,219.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,773.91 / $2,773.91 / $2,773.91
| Professional | | $2,773.91 | $2,773.91 | $2,773.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,961.70 / $3,634.92 / $5,032.20
| Facility | | $1,961.70 | $3,634.92 | $5,032.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,575.36 / $3,238.32
| Professional | | $2,549.86 | $2,575.36 | $3,238.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,331.48 / $1,686.54 / $3,861.29
| Facility | | $1,331.48 | $1,686.54 | $3,861.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,331.48 / $3,772.52
| Professional | | $932.03 | $1,331.48 | $3,772.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,331.48 / $3,550.61
| Professional | | $932.03 | $1,331.48 | $3,550.61 |