- 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
- $1,819.70 / $2,137.96 / $3,235.94
| Professional | | $1,819.70 | $2,137.96 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,137.96 / $2,818.38
| Professional | | $1,949.84 | $2,137.96 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,238.72 / $5,495.41
| Professional | | $1,698.24 | $2,238.72 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,995.26 / $4,466.84
| Professional | | $1,905.46 | $1,995.26 | $4,466.84 |
- 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
- $1,584.89 / $2,137.96 / $4,786.30
| Professional | | $1,584.89 | $2,137.96 | $4,786.30 |