- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,430.59 / $3,793.53 / $9,125.84
| Facility | | $2,430.59 | $3,793.53 | $9,125.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,115.84 / $3,565.63 / $5,095.95
| Professional | | $2,115.84 | $3,565.63 | $5,095.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,106.32 / $3,461.84 / $7,185.70
| Facility | | $2,106.32 | $3,461.84 | $7,185.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,900.84 / $3,128.68 / $4,310.78
| Professional | | $1,900.84 | $3,128.68 | $4,310.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,310.16 / $1,431.64 / $2,697.68
| Facility | | $1,310.16 | $1,431.64 | $2,697.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,494.34 / $5,494.34 / $5,494.34
| Professional | | $5,494.34 | $5,494.34 | $5,494.34 |