- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,995.26 / $4,466.84
| Facility | | $776.25 | $1,995.26 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $2,290.87 / $3,801.89
| Professional | | $616.60 | $2,290.87 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,011.87 / $5,011.87
| Professional | | $2,818.38 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,265.80
| Facility | | $3,388.44 | $3,388.44 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $2,630.27 / $5,623.41
| Professional | | $851.14 | $2,630.27 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $2,691.53 / $7,585.78
| Facility | | $794.33 | $2,691.53 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $2,187.76 / $5,248.07
| Professional | | $645.65 | $2,187.76 | $5,248.07 |