- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,548.13 / $7,762.47
| Facility | | $1,698.24 | $3,548.13 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,548.13 / $8,317.64
| Professional | | $2,290.87 | $3,548.13 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $4,786.30
| Professional | | $2,187.76 | $2,290.87 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,890.45 / $7,762.47
| Professional | | $2,511.89 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,090.30 / $6,760.83
| Professional | | $2,884.03 | $3,090.30 | $6,760.83 |
- 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
- $2,454.71 / $3,801.89 / $7,585.78
| Professional | | $2,454.71 | $3,801.89 | $7,585.78 |