- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,108.88 / $4,411.05 / $10,611.37
| Facility | | $3,108.88 | $4,411.05 | $10,611.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,310.35 / $3,475.37 / $5,465.85
| Professional | | $2,310.35 | $3,475.37 | $5,465.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,528.60 / $4,032.76 / $8,355.41
| Facility | | $2,528.60 | $4,032.76 | $8,355.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,828.04 / $2,944.80 / $5,012.51
| Professional | | $1,828.04 | $2,944.80 | $5,012.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,527.87 / $1,597.41 / $2,652.23
| Facility | | $1,527.87 | $1,597.41 | $2,652.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,157.00 / $6,050.73 / $6,050.73
| Professional | | $2,157.00 | $6,050.73 | $6,050.73 |