- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,585.78 / $7,585.78
| Facility | | $3,467.37 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $2,238.72
| Professional | | $1,479.11 | $1,778.28 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $2,754.23
| Facility | | $1,318.26 | $2,089.30 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $1,318.26
| Professional | | $933.25 | $933.25 | $1,318.26 |