- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,090.30 / $7,762.47
| Facility | | $1,698.24 | $3,090.30 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,090.30 / $7,762.47
| Professional | | $2,951.21 | $3,090.30 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $4,265.80
| Professional | | $2,818.38 | $3,548.13 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $7,762.47
| Professional | | $2,754.23 | $3,715.35 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,309.57 / $6,760.83
| Professional | | $2,951.21 | $6,309.57 | $6,760.83 |
- 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 / $3,801.89 / $8,128.31
| Professional | | $2,344.23 | $3,801.89 | $8,128.31 |