- 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
- $3,235.94 / $3,801.89 / $6,025.60
| Professional | | $3,235.94 | $3,801.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $4,073.80 / $5,248.07
| Professional | | $2,344.23 | $4,073.80 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,981.07 / $9,772.37
| Professional | | $3,019.95 | $3,981.07 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,630.78 / $7,943.28
| Professional | | $3,467.37 | $3,630.78 | $7,943.28 |
- 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
- $2,754.23 / $3,715.35 / $8,709.64
| Professional | | $2,754.23 | $3,715.35 | $8,709.64 |