- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $7,762.47
| Facility | | $1,698.24 | $2,398.83 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,398.83 / $5,128.61
| Professional | | $1,258.93 | $2,398.83 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,454.71 / $3,019.95
| Professional | | $2,290.87 | $2,454.71 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,570.40 / $4,897.79
| Professional | | $1,737.80 | $2,570.40 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $4,265.80
| Professional | | $3,981.07 | $3,981.07 | $4,265.80 |
- 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 / $2,691.53 / $5,495.41
| Professional | | $1,737.80 | $2,691.53 | $5,495.41 |