- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,214.11 / $4,560.35 / $10,970.55
| Facility | | $3,214.11 | $4,560.35 | $10,970.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,483.38 / $3,927.58 / $5,650.86
| Professional | | $2,483.38 | $3,927.58 | $5,650.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,921.92 / $4,169.26 / $8,638.23
| Facility | | $2,921.92 | $4,169.26 | $8,638.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,162.52 / $3,428.66 / $5,182.17
| Professional | | $2,162.52 | $3,428.66 | $5,182.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,763.66 / $3,763.66 / $3,763.66
| Facility | | $3,763.66 | $3,763.66 | $3,763.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,003.00 / $10,396.14 / $10,396.14
| Professional | | $2,003.00 | $10,396.14 | $10,396.14 |