- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,651.21 / $2,423.90 / $6,878.86
| Facility | | $1,651.21 | $2,423.90 | $6,878.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.69 / $1,205.39 / $3,212.16
| Professional | | $381.69 | $1,205.39 | $3,212.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,426.35 / $2,269.75 / $5,416.43
| Facility | | $1,426.35 | $2,269.75 | $5,416.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.35 / $1,193.45 / $2,755.02
| Professional | | $339.35 | $1,193.45 | $2,755.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.26 / $684.30 / $1,831.90
| Facility | | $276.26 | $684.30 | $1,831.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,869.46 / $3,853.58 / $3,853.58
| Professional | | $1,869.46 | $3,853.58 | $3,853.58 |