- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,019.95 / $6,606.93
| Facility | | $1,288.25 | $3,019.95 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,754.23 / $3,981.07
| Professional | | $1,862.09 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,715.35 / $4,365.16
| Professional | | $2,344.23 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,019.95 / $3,890.45
| Professional | | $2,137.96 | $3,019.95 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,818.38 / $6,309.57
| Facility | | $346.74 | $2,818.38 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $22,908.68
| Professional | | $1,995.26 | $2,691.53 | $22,908.68 |
- 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
- $1,905.46 / $2,290.87 / $4,073.80
| Professional | | $1,905.46 | $2,290.87 | $4,073.80 |