- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $7,762.47
| Facility | | $1,698.24 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $6,760.83
| Professional | | $1,905.46 | $2,884.03 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $3,630.78
| Professional | | $1,862.09 | $2,137.96 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,090.30 / $6,309.57
| Professional | | $2,344.23 | $3,090.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,344.23 / $5,495.41
| Professional | | $2,238.72 | $2,344.23 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $6,165.95
| Professional | | $2,137.96 | $3,019.95 | $6,165.95 |