- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,073.80 / $7,762.47
| Facility | | $1,698.24 | $4,073.80 | $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 / $2,398.83 / $2,818.38
| Professional | | $2,344.23 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $4,677.35
| Professional | | $1,621.81 | $2,398.83 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,073.80
| Professional | | $3,715.35 | $3,715.35 | $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
- $1,659.59 / $2,454.71 / $5,128.61
| Professional | | $1,659.59 | $2,454.71 | $5,128.61 |