- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $5,623.41
| Facility | | $2,187.76 | $2,187.76 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $2,951.21
| Professional | | $2,137.96 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,309.57 / $7,079.46
| Professional | | $4,570.88 | $6,309.57 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $4,570.88
| Professional | | $3,630.78 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $5,623.41
| Facility | | $1,905.46 | $2,398.83 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,715.35 / $6,309.57
| Professional | | $1,318.26 | $3,715.35 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $3,235.94 / $5,370.32
| Professional | | $1,318.26 | $3,235.94 | $5,370.32 |