- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,311.31 / $7,943.28
| Facility | | $2,344.23 | $3,311.31 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,818.38 / $4,265.80
| Professional | | $1,862.09 | $2,818.38 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $6,309.57
| Facility | | $2,570.40 | $3,162.28 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $3,630.78
| Professional | | $1,778.28 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,380.38 / $2,570.40
| Facility | | $1,348.96 | $1,380.38 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Professional | | $7,079.46 | $7,079.46 | $7,079.46 |