- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $4,466.84
| Facility | | $1,737.80 | $2,344.23 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,905.46 / $2,344.23
| Professional | | $1,698.24 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,011.87 / $5,623.41
| Professional | | $3,630.78 | $5,011.87 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,311.31
| Professional | | $2,630.27 | $2,630.27 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $4,466.84
| Facility | | $1,513.56 | $1,905.46 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,951.21 / $5,011.87
| Professional | | $1,047.13 | $2,951.21 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,570.40 / $4,265.80
| Professional | | $1,047.13 | $2,570.40 | $4,265.80 |