- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.33 / $11,491.76 / $11,491.76
| Facility | | $1,486.33 | $11,491.76 | $11,491.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,140.02 / $1,379.01 / $2,003.57
| Professional | | $1,140.02 | $1,379.01 | $2,003.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,916.38 / $3,157.86 / $3,774.13
| Professional | | $2,916.38 | $3,157.86 | $3,774.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,133.61 / $3,455.38 / $4,462.12
| Professional | | $2,133.61 | $3,455.38 | $4,462.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,486.33 / $1,832.84 / $2,526.76
| Facility | | $1,486.33 | $1,832.84 | $2,526.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.39 / $2,659.25 / $12,056.47
| Professional | | $1,567.39 | $2,659.25 | $12,056.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,567.39 / $2,202.46 / $3,207.95
| Professional | | $1,567.39 | $2,202.46 | $3,207.95 |