- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,818.38 / $7,762.47
| Facility | | $1,698.24 | $2,818.38 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,884.03 / $7,585.78
| Professional | | $2,691.53 | $2,884.03 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,818.38 / $3,890.45
| Professional | | $2,570.40 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,548.13 / $7,413.10
| Professional | | $2,454.71 | $3,548.13 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,370.32 / $6,165.95
| Professional | | $2,454.71 | $5,370.32 | $6,165.95 |
- 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
- $2,344.23 / $3,548.13 / $6,918.31
| Professional | | $2,344.23 | $3,548.13 | $6,918.31 |