- 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
- $1,230.27 / $2,290.87 / $5,888.44
| Professional | | $1,230.27 | $2,290.87 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,290.87 / $2,884.03
| Professional | | $2,041.74 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $4,786.30
| Professional | | $1,698.24 | $2,511.89 | $4,786.30 |
- 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
- $1,778.28 / $2,630.27 / $5,248.07
| Professional | | $1,778.28 | $2,630.27 | $5,248.07 |