- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,311.31 / $7,762.47
| Facility | | $1,698.24 | $3,311.31 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,090.30 / $4,897.79
| Professional | | $2,630.27 | $3,090.30 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,090.30 / $4,073.80
| Professional | | $2,630.27 | $3,090.30 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,311.31 / $7,943.28
| Professional | | $2,454.71 | $3,311.31 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,884.03 / $6,456.54
| Professional | | $2,754.23 | $2,884.03 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $6,309.57
| Facility | | $645.65 | $2,344.23 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,019.95 / $6,918.31
| Professional | | $2,238.72 | $3,019.95 | $6,918.31 |