- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $7,762.47
| Facility | | $1,698.24 | $2,884.03 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,884.03 / $7,943.28
| Professional | | $1,513.56 | $2,884.03 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,388.44 / $3,630.78
| Professional | | $2,951.21 | $3,388.44 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,090.30 / $5,888.44
| Professional | | $2,089.30 | $3,090.30 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,128.61
| Professional | | $4,786.30 | $4,786.30 | $5,128.61 |
- 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
- $2,089.30 / $3,090.30 / $6,606.93
| Professional | | $2,089.30 | $3,090.30 | $6,606.93 |