- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,951.21 / $7,762.47
| Facility | | $1,698.24 | $2,951.21 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,951.21 / $6,760.83
| Professional | | $1,584.89 | $2,951.21 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,511.89 / $3,715.35
| Professional | | $2,344.23 | $2,511.89 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $6,025.60
| Professional | | $2,137.96 | $3,019.95 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $5,248.07
| Professional | | $4,897.79 | $4,897.79 | $5,248.07 |
- 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
- $1,995.26 / $3,162.28 / $6,760.83
| Professional | | $1,995.26 | $3,162.28 | $6,760.83 |