- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,187.76 / $7,762.47
| Facility | | $1,698.24 | $2,187.76 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $5,370.32
| Professional | | $2,089.30 | $2,187.76 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,778.28 / $3,090.30
| Professional | | $1,621.81 | $1,778.28 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,691.53 / $5,495.41
| Professional | | $1,949.84 | $2,691.53 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,365.16 / $4,897.79
| Professional | | $2,187.76 | $4,365.16 | $4,897.79 |
- 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
- $1,862.09 / $2,691.53 / $5,495.41
| Professional | | $1,862.09 | $2,691.53 | $5,495.41 |