- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,388.44 / $7,762.47
| Facility | | $1,698.24 | $3,388.44 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $7,762.47
| Professional | | $2,187.76 | $3,388.44 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,754.23 / $4,073.80
| Professional | | $2,570.40 | $2,754.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $7,244.36
| Professional | | $2,754.23 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,691.53 / $6,309.57
| Professional | | $2,570.40 | $2,691.53 | $6,309.57 |
- 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
- $2,511.89 / $3,467.37 / $7,244.36
| Professional | | $2,511.89 | $3,467.37 | $7,244.36 |