- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $7,762.47
| Facility | | $1,698.24 | $2,187.76 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,187.76 / $5,128.61
| Professional | | $1,148.15 | $2,187.76 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,290.87 / $2,754.23
| Professional | | $2,238.72 | $2,290.87 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,344.23 / $4,466.84
| Professional | | $1,584.89 | $2,344.23 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,890.45
| Professional | | $3,630.78 | $3,630.78 | $3,890.45 |
- 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
- $1,584.89 / $2,344.23 / $5,011.87
| Professional | | $1,584.89 | $2,344.23 | $5,011.87 |