- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $10,964.78 / $10,964.78
| Facility | | $4,897.79 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $3,981.07
| Professional | | $2,187.76 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,760.83
| Professional | | $4,897.79 | $4,897.79 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,801.89 / $6,025.60
| Facility | | $2,089.30 | $3,801.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,467.37 / $3,467.37
| Professional | | $3,311.31 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- 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 |