- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,570.40 / $7,762.47
| Facility | | $1,698.24 | $2,570.40 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,398.83 / $3,890.45
| Professional | | $2,089.30 | $2,398.83 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,398.83 / $3,162.28
| Professional | | $2,137.96 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,630.27 / $6,165.95
| Professional | | $1,949.84 | $2,630.27 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,290.87 / $5,011.87
| Professional | | $2,187.76 | $2,290.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,290.87 / $6,309.57
| Facility | | $645.65 | $2,290.87 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,570.40 / $5,370.32
| Professional | | $1,819.70 | $2,570.40 | $5,370.32 |