- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,715.35 / $4,786.30
| Facility | | $3,162.28 | $3,715.35 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,570.40 / $3,715.35
| Professional | | $1,737.80 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $660.69 / $891.25
| Facility | | $549.54 | $660.69 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,137.96 / $3,311.31
| Professional | | $2,041.74 | $2,137.96 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,570.40 / $6,760.83
| Facility | | $2,041.74 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,818.38 / $3,162.28
| Facility | | $1,318.26 | $2,818.38 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,905.46
| Professional | | $1,318.26 | $1,318.26 | $1,905.46 |