- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,510.21 / $2,886.74 / $5,020.42
| Facility | | $2,510.21 | $2,886.74 | $5,020.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,957.96 / $2,886.74 / $2,886.74
| Professional | | $1,957.96 | $2,886.74 | $2,886.74 |
- 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
- $1,757.36 / $2,582.52 / $3,047.37
| Professional | | $1,757.36 | $2,582.52 | $3,047.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,895.90 / $2,115.08 / $5,433.36
| Facility | | $1,895.90 | $2,115.08 | $5,433.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,087.08 / $1,108.77 / $1,478.00
| Professional | | $1,087.08 | $1,108.77 | $1,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,054.29 / $1,054.29 / $1,859.41
| Professional | | $1,054.29 | $1,054.29 | $1,859.41 |