- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,801.89 / $8,912.51
| Facility | | $2,691.53 | $3,801.89 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,511.89 / $4,265.80
| Professional | | $1,513.56 | $2,511.89 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,630.78 / $7,079.46
| Facility | | $2,884.03 | $3,630.78 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $4,073.80
| Professional | | $1,513.56 | $2,238.72 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $977.24 / $2,137.96
| Facility | | $741.31 | $977.24 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,677.35
| Professional | | $4,265.80 | $4,265.80 | $4,677.35 |