- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $7,762.47
| Facility | | $1,698.24 | $2,511.89 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $2,511.89 / $2,818.38
| Professional | | $977.24 | $2,511.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,951.21 / $3,981.07
| Professional | | $2,691.53 | $2,951.21 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,897.79
| Professional | | $1,995.26 | $2,691.53 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $4,677.35
| Professional | | $3,801.89 | $3,801.89 | $4,677.35 |
- 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
- $1,318.26 / $2,818.38 / $5,888.44
| Professional | | $1,318.26 | $2,818.38 | $5,888.44 |