- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,459.08 / $2,219.13 / $5,064.28
| Facility | | $1,459.08 | $2,219.13 | $5,064.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.08 / $1,459.08 / $1,553.39
| Professional | | $1,459.08 | $1,459.08 | $1,553.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.61 / $3,256.57 / $5,492.35
| Facility | | $1,675.61 | $3,256.57 | $5,492.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,131.75 / $1,526.76 / $4,240.93
| Professional | | $1,131.75 | $1,526.76 | $4,240.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,442.43 / $6,152.95 / $12,736.61
| Facility | | $1,442.43 | $6,152.95 | $12,736.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,549.86 / $2,549.86 / $3,187.33
| Professional | | $2,549.86 | $2,549.86 | $3,187.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,020.80 / $1,020.80 / $1,309.29
| Professional | | $1,020.80 | $1,020.80 | $1,309.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $932.03 / $1,664.35 / $3,931.19
| Professional | | $932.03 | $1,664.35 | $3,931.19 |