- 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
- $1,445.44 / $2,290.87 / $5,888.44
| Professional | | $1,445.44 | $2,290.87 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,238.72 / $2,754.23
| Professional | | $2,137.96 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $4,677.35
| Professional | | $1,737.80 | $2,630.27 | $4,677.35 |
- 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 / $2,754.23 / $5,248.07
| Professional | | $1,778.28 | $2,754.23 | $5,248.07 |