- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $7,762.47
| Facility | | $1,698.24 | $2,691.53 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,691.53 / $6,918.31
| Professional | | $2,511.89 | $2,691.53 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,884.03 / $3,467.37
| Professional | | $2,511.89 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,467.37 / $6,918.31
| Professional | | $2,454.71 | $3,467.37 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,495.41 / $6,025.60
| Professional | | $2,630.27 | $5,495.41 | $6,025.60 |
- 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
- $2,089.30 / $3,467.37 / $7,079.46
| Professional | | $2,089.30 | $3,467.37 | $7,079.46 |