- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,235.94 / $7,762.47
| Facility | | $1,698.24 | $3,235.94 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,235.94 / $7,585.78
| Professional | | $1,698.24 | $3,235.94 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $3,981.07
| Professional | | $2,630.27 | $2,951.21 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $6,606.93
| Professional | | $2,290.87 | $3,235.94 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,754.40
| Professional | | $5,248.07 | $5,248.07 | $5,754.40 |
- 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
- $2,290.87 / $3,467.37 / $7,413.10
| Professional | | $2,290.87 | $3,467.37 | $7,413.10 |