- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $5,754.40 / $75,857.76
| Facility | | $1,698.24 | $5,754.40 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,454.71 / $4,073.80
| Professional | | $2,089.30 | $2,454.71 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $3,090.30
| Professional | | $1,995.26 | $2,398.83 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,570.40 / $6,760.83
| Professional | | $1,698.24 | $2,570.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,137.96 / $4,466.84
| Professional | | $2,041.74 | $2,137.96 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,290.87 / $6,309.57
| Facility | | $645.65 | $2,290.87 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,290.87 / $5,128.61
| Professional | | $1,737.80 | $2,290.87 | $5,128.61 |