- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,987.51 / $5,468.89 / $5,468.89
| Facility | | $2,987.51 | $5,468.89 | $5,468.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.40 / $1,740.10 / $1,839.54
| Professional | | $1,496.40 | $1,740.10 | $1,839.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,149.34 / $2,244.60 / $2,503.26
| Facility | | $2,149.34 | $2,244.60 | $2,503.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,163.35 / $1,368.66 / $1,368.66
| Professional | | $1,163.35 | $1,368.66 | $1,368.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,355.80 / $4,355.80 / $7,657.23
| Facility | | $4,355.80 | $4,355.80 | $7,657.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,193.21 / $2,690.48 / $6,098.48
| Professional | | $1,193.21 | $2,690.48 | $6,098.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $766.45 / $1,491.52 / $3,610.45
| Professional | | $766.45 | $1,491.52 | $3,610.45 |