- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,983.30 / $4,230.68 / $10,177.49
| Facility | | $2,983.30 | $4,230.68 | $10,177.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,039.13 / $3,465.86 / $5,307.49
| Professional | | $2,039.13 | $3,465.86 | $5,307.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,425.21 / $3,867.86 / $8,013.78
| Facility | | $2,425.21 | $3,867.86 | $8,013.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,982.88 / $2,916.12 / $4,807.56
| Professional | | $1,982.88 | $2,916.12 | $4,807.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,485.58 / $2,004.48 / $3,345.72
| Facility | | $1,485.58 | $2,004.48 | $3,345.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,041.00 / $8,942.37 / $8,942.37
| Professional | | $8,041.00 | $8,942.37 | $8,942.37 |