- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $7,762.47
| Facility | | $1,698.24 | $2,454.71 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,235.94 / $7,762.47
| Professional | | $2,454.71 | $3,235.94 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,884.03 / $4,466.84
| Professional | | $2,570.40 | $2,884.03 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $7,585.78
| Professional | | $2,691.53 | $3,388.44 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,951.21 / $6,606.93
| Professional | | $2,818.38 | $2,951.21 | $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 |