- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,073.80 / $7,943.28
| Facility | | $1,698.24 | $4,073.80 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,238.72 / $6,025.60
| Professional | | $1,174.90 | $2,238.72 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,290.87 / $2,818.38
| Professional | | $2,137.96 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $4,570.88
| Professional | | $1,621.81 | $2,398.83 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,981.07
| Professional | | $3,715.35 | $3,715.35 | $3,981.07 |
- 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
- $1,513.56 / $2,398.83 / $5,128.61
| Professional | | $1,513.56 | $2,398.83 | $5,128.61 |