- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,235.94 / $6,606.93
| Facility | | $1,288.25 | $3,235.94 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $4,265.80
| Professional | | $2,290.87 | $2,884.03 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $4,168.69
| Professional | | $2,754.23 | $3,630.78 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,951.21 / $6,309.57
| Facility | | $346.74 | $2,951.21 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,019.95 / $23,442.29
| Professional | | $2,290.87 | $3,019.95 | $23,442.29 |
- 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
- $2,187.76 / $2,754.23 / $4,365.16
| Professional | | $2,187.76 | $2,754.23 | $4,365.16 |