- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,237.05 / $3,172.42 / $7,631.68
| Facility | | $2,237.05 | $3,172.42 | $7,631.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,805.55 / $2,938.53 / $4,261.60
| Professional | | $1,805.55 | $2,938.53 | $4,261.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,818.56 / $2,900.35 / $6,009.20
| Facility | | $1,818.56 | $2,900.35 | $6,009.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,508.87 / $2,421.73 / $3,604.99
| Professional | | $1,508.87 | $2,421.73 | $3,604.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,341.72 / $1,393.85 / $2,572.61
| Facility | | $1,341.72 | $1,393.85 | $2,572.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,159.00 / $7,159.00 / $7,159.00
| Professional | | $7,159.00 | $7,159.00 | $7,159.00 |