- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $5,754.40
| Facility | | $2,238.72 | $2,238.72 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $2,884.03
| Professional | | $2,137.96 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,165.95 / $7,244.36
| Professional | | $4,168.69 | $6,165.95 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,570.88
| Professional | | $3,715.35 | $3,715.35 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,454.71 / $5,754.40
| Facility | | $1,905.46 | $2,454.71 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,801.89 / $6,456.54
| Professional | | $1,348.96 | $3,801.89 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $3,235.94 / $5,495.41
| Professional | | $1,348.96 | $3,235.94 | $5,495.41 |