- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,388.44 / $7,762.47
| Facility | | $1,698.24 | $3,388.44 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $4,677.35
| Professional | | $2,630.27 | $3,162.28 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,162.28 / $4,073.80
| Professional | | $2,511.89 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,311.31 / $8,128.31
| Professional | | $2,454.71 | $3,311.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,951.21 / $6,456.54
| Professional | | $2,818.38 | $2,951.21 | $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
- $2,344.23 / $3,162.28 / $7,079.46
| Professional | | $2,344.23 | $3,162.28 | $7,079.46 |