- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,162.28 / $7,762.47
| Facility | | $1,698.24 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,235.94 / $7,585.78
| Professional | | $2,884.03 | $3,235.94 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,265.80 / $8,709.64
| Professional | | $3,235.94 | $4,265.80 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,090.30 / $6,606.93
| Professional | | $2,951.21 | $3,090.30 | $6,606.93 |
- 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
- $2,570.40 / $3,630.78 / $7,244.36
| Professional | | $2,570.40 | $3,630.78 | $7,244.36 |