- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,679.84 / $5,031.68 / $7,774.96
| Facility | | $2,679.84 | $5,031.68 | $7,774.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.25 / $2,118.44 / $2,605.44
| Professional | | $1,826.25 | $2,118.44 | $2,605.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,043.75 / $3,043.75 / $3,043.75
| Professional | | $3,043.75 | $3,043.75 | $3,043.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,152.54 / $3,988.53 / $4,930.27
| Facility | | $2,152.54 | $3,988.53 | $4,930.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,996.70 / $2,435.00 / $3,275.83
| Facility | | $1,996.70 | $2,435.00 | $3,275.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.70 / $1,461.00 / $12,126.30
| Professional | | $1,022.70 | $1,461.00 | $12,126.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,022.70 / $1,461.00 / $3,652.50
| Professional | | $1,022.70 | $1,461.00 | $3,652.50 |