- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,311.31 / $6,606.93
| Facility | | $1,288.25 | $3,311.31 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,235.94 / $5,623.41
| Professional | | $2,691.53 | $3,235.94 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,548.13 / $3,890.45
| Professional | | $2,884.03 | $3,548.13 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,715.35 / $4,168.69
| Professional | | $3,019.95 | $3,715.35 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $3,235.94 / $7,244.36
| Facility | | $489.78 | $3,235.94 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,388.44 / $21,877.62
| Professional | | $2,630.27 | $3,388.44 | $21,877.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,949.84 / $6,165.95
| Facility | | $346.74 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $4,677.35
| Professional | | $2,511.89 | $3,090.30 | $4,677.35 |