- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,981.07 / $9,549.93
| Facility | | $2,818.38 | $3,981.07 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,388.44 / $5,128.61
| Professional | | $2,238.72 | $3,388.44 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,801.89 / $7,585.78
| Facility | | $3,090.30 | $3,801.89 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,884.03 / $4,365.16
| Professional | | $2,041.74 | $2,884.03 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $8,709.64 / $8,709.64 / $8,709.64
| Professional | | $8,709.64 | $8,709.64 | $8,709.64 |