- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,090.30 / $7,762.47
| Facility | | $1,698.24 | $3,090.30 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,090.30 / $3,801.89
| Professional | | $1,778.28 | $3,090.30 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,951.21 / $3,890.45
| Professional | | $2,630.27 | $2,951.21 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $6,456.54
| Professional | | $2,344.23 | $3,388.44 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $5,495.41
| Professional | | $5,128.61 | $5,128.61 | $5,495.41 |
- 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
- $2,398.83 / $3,467.37 / $7,079.46
| Professional | | $2,398.83 | $3,467.37 | $7,079.46 |