- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.59 / $2,406.59 / $6,188.36
| Facility | | $2,406.59 | $2,406.59 | $6,188.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.59 / $3,231.70 / $3,231.70
| Professional | | $2,406.59 | $3,231.70 | $3,231.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,175.02 / $6,927.53 / $7,735.46
| Professional | | $5,175.02 | $6,927.53 | $7,735.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,950.35 / $3,950.35 / $5,799.29
| Professional | | $3,950.35 | $3,950.35 | $5,799.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,062.79 / $2,612.86 / $6,188.36
| Facility | | $2,062.79 | $2,612.86 | $6,188.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,753.37 / $4,125.58 / $6,875.96
| Professional | | $1,753.37 | $4,125.58 | $6,875.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,443.95 / $3,506.74 / $5,844.57
| Professional | | $1,443.95 | $3,506.74 | $5,844.57 |