- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $7,762.47
| Facility | | $1,698.24 | $2,691.53 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,691.53 / $5,888.44
| Professional | | $1,412.54 | $2,691.53 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,905.46 / $3,388.44
| Professional | | $1,737.80 | $1,905.46 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $5,495.41
| Professional | | $1,862.09 | $2,630.27 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $4,786.30
| Professional | | $4,466.84 | $4,466.84 | $4,786.30 |
- 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
- $1,737.80 / $2,884.03 / $6,165.95
| Professional | | $1,737.80 | $2,884.03 | $6,165.95 |