- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $7,762.47
| Facility | | $1,698.24 | $2,754.23 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,754.23 / $7,585.78
| Professional | | $2,691.53 | $2,754.23 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,019.95 / $4,466.84
| Professional | | $2,691.53 | $3,019.95 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,801.89 / $6,918.31
| Professional | | $2,630.27 | $3,801.89 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,495.41 / $7,079.46
| Professional | | $2,630.27 | $5,495.41 | $7,079.46 |
- 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
- $2,398.83 / $3,630.78 / $7,585.78
| Professional | | $2,398.83 | $3,630.78 | $7,585.78 |