- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $7,762.47
| Facility | | $1,698.24 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,344.23 / $6,025.60
| Professional | | $1,318.26 | $2,344.23 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,089.30 / $2,754.23
| Professional | | $1,949.84 | $2,089.30 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,570.40 / $4,897.79
| Professional | | $1,778.28 | $2,570.40 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,265.80 / $4,265.80
| Professional | | $3,890.45 | $4,265.80 | $4,265.80 |
- 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
- $1,819.70 / $2,630.27 / $5,495.41
| Professional | | $1,819.70 | $2,630.27 | $5,495.41 |