- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $7,762.47
| Facility | | $1,698.24 | $2,238.72 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,238.72 / $5,248.07
| Professional | | $1,174.90 | $2,238.72 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,818.38 / $3,311.31
| Professional | | $2,290.87 | $2,818.38 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,398.83 / $4,570.88
| Professional | | $1,584.89 | $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
- $1,584.89 / $2,398.83 / $5,128.61
| Professional | | $1,584.89 | $2,398.83 | $5,128.61 |