- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $6,760.83
| Facility | | $2,630.27 | $3,548.13 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,818.38 / $4,466.84
| Professional | | $2,041.74 | $2,818.38 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,244.36 / $8,511.38
| Professional | | $4,897.79 | $7,244.36 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $5,370.32
| Professional | | $4,265.80 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,691.53 / $6,760.83
| Facility | | $2,089.30 | $2,691.53 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,467.37 / $7,585.78
| Professional | | $1,479.11 | $3,467.37 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,630.78 / $6,309.57
| Professional | | $1,479.11 | $3,630.78 | $6,309.57 |