- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,162.28 / $6,606.93
| Facility | | $1,288.25 | $3,162.28 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $4,168.69
| Professional | | $2,187.76 | $2,818.38 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,801.89 / $4,365.16
| Professional | | $2,691.53 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,884.03 / $7,244.36
| Facility | | $346.74 | $2,884.03 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,951.21 / $17,782.79
| Professional | | $2,238.72 | $2,951.21 | $17,782.79 |
- 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
- $2,137.96 / $2,951.21 / $4,265.80
| Professional | | $2,137.96 | $2,951.21 | $4,265.80 |