- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,189.69 / $2,919.60 / $7,007.04
| Facility | | $2,189.69 | $2,919.60 | $7,007.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,160.51 / $2,160.51 / $3,123.97
| Professional | | $2,160.51 | $2,160.51 | $3,123.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.74 / $1,897.74 / $2,561.94
| Facility | | $1,897.74 | $1,897.74 | $2,561.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,556.09 / $3,556.09 / $4,260.59
| Professional | | $3,556.09 | $3,556.09 | $4,260.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,160.51 / $2,753.11 / $4,817.34
| Facility | | $2,160.51 | $2,753.11 | $4,817.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,226.23 / $3,853.87
| Professional | | $1,226.23 | $1,226.23 | $3,853.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,226.23 / $1,868.54
| Professional | | $1,226.23 | $1,226.23 | $1,868.54 |