- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $3,357.54 / $5,839.20
| Facility | | $2,919.60 | $3,357.54 | $5,839.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.66 / $3,211.56 / $3,357.54
| Professional | | $2,481.66 | $3,211.56 | $3,357.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.89 / $652.76 / $878.17
| Facility | | $537.89 | $652.76 | $878.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $424.69 / $515.80 / $2,773.62
| Professional | | $424.69 | $515.80 | $2,773.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,859.79 / $2,372.17 / $6,319.47
| Facility | | $1,859.79 | $2,372.17 | $6,319.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,289.56 / $2,029.70 / $4,193.50
| Professional | | $1,289.56 | $2,029.70 | $4,193.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,226.23 / $2,919.60
| Professional | | $1,226.23 | $1,226.23 | $2,919.60 |