- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $25,703.96
| Facility | | $1,096.48 | $1,445.44 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,951.21 / $5,495.41
| Professional | | $2,511.89 | $2,951.21 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,025.60 / $8,317.64
| Facility | | $5,128.61 | $6,025.60 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,981.07 / $4,677.35
| Professional | | $2,630.27 | $3,981.07 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $6,456.54
| Professional | | $2,187.76 | $3,388.44 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,659.59 / $5,248.07
| Facility | | $660.69 | $1,659.59 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,884.03 / $4,677.35
| Professional | | $2,089.30 | $2,884.03 | $4,677.35 |