- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $7,762.47
| Facility | | $1,698.24 | $2,290.87 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,290.87 / $5,495.41
| Professional | | $1,202.26 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,884.03 / $3,090.30
| Professional | | $2,344.23 | $2,884.03 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $4,677.35
| Professional | | $1,698.24 | $2,398.83 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $4,073.80
| Professional | | $3,801.89 | $3,801.89 | $4,073.80 |
- 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
- $1,621.81 / $2,511.89 / $5,248.07
| Professional | | $1,621.81 | $2,511.89 | $5,248.07 |