- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,019.95 / $7,762.47
| Facility | | $1,698.24 | $3,019.95 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $6,918.31
| Professional | | $2,884.03 | $3,019.95 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,754.23 / $4,168.69
| Professional | | $2,511.89 | $2,754.23 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $7,585.78
| Professional | | $2,630.27 | $3,548.13 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $6,025.60 / $6,606.93
| Professional | | $3,019.95 | $6,025.60 | $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
- $2,511.89 / $3,715.35 / $7,413.10
| Professional | | $2,511.89 | $3,715.35 | $7,413.10 |