- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,370.32 / $7,943.28
| Facility | | $3,630.78 | $5,370.32 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $5,011.87
| Professional | | $2,187.76 | $2,691.53 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,884.03 / $4,786.30
| Facility | | $1,071.52 | $2,884.03 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,818.38 / $5,128.61
| Professional | | $2,398.83 | $2,818.38 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,951.21 / $5,248.07
| Professional | | $2,041.74 | $2,951.21 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,019.95 / $4,897.79
| Professional | | $2,691.53 | $3,019.95 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $3,090.30 / $5,370.32
| Facility | | $1,047.13 | $3,090.30 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $6,456.54
| Professional | | $2,454.71 | $3,467.37 | $6,456.54 |