- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,248.07 / $5,248.07
| Facility | | $2,041.74 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,238.72 / $2,754.23
| Professional | | $1,949.84 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,623.41 / $6,606.93
| Professional | | $4,265.80 | $5,623.41 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,168.69
| Professional | | $3,388.44 | $3,388.44 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,238.72 / $5,248.07
| Facility | | $1,737.80 | $2,238.72 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,467.37 / $5,888.44
| Professional | | $1,230.27 | $3,467.37 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,951.21 / $5,011.87
| Professional | | $1,230.27 | $2,951.21 | $5,011.87 |