- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,951.21 / $7,762.47
| Facility | | $1,698.24 | $2,951.21 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,951.21 / $6,760.83
| Professional | | $2,754.23 | $2,951.21 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,630.27 / $4,168.69
| Professional | | $2,398.83 | $2,630.27 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,388.44 / $7,585.78
| Professional | | $2,630.27 | $3,388.44 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $5,888.44 / $6,606.93
| Professional | | $3,019.95 | $5,888.44 | $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
- $2,398.83 / $3,467.37 / $7,413.10
| Professional | | $2,398.83 | $3,467.37 | $7,413.10 |