- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,685.44 / $3,810.25 / $9,166.07
| Facility | | $2,685.44 | $3,810.25 | $9,166.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,074.90 / $3,281.55 / $4,721.39
| Professional | | $2,074.90 | $3,281.55 | $4,721.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,441.31 / $3,483.48 / $7,217.38
| Facility | | $2,441.31 | $3,483.48 | $7,217.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,806.82 / $2,864.70 / $4,329.79
| Professional | | $1,806.82 | $2,864.70 | $4,329.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.97 / $3,162.97 / $3,162.97
| Facility | | $3,162.97 | $3,162.97 | $3,162.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,632.00 / $7,309.74 / $7,309.74
| Professional | | $1,632.00 | $7,309.74 | $7,309.74 |