- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,073.80 / $7,762.47
| Facility | | $1,698.24 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,073.80 / $6,165.95
| Professional | | $3,548.13 | $4,073.80 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,981.07 / $5,248.07
| Professional | | $2,511.89 | $3,981.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,073.80 / $10,471.29
| Professional | | $1,995.26 | $4,073.80 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,890.45 / $7,762.47
| Professional | | $3,715.35 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $6,309.57
| Facility | | $645.65 | $2,344.23 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,981.07 / $9,120.11
| Professional | | $2,951.21 | $3,981.07 | $9,120.11 |