- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,630.27 / $6,606.93
| Facility | | $1,288.25 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $4,897.79
| Professional | | $2,454.71 | $2,884.03 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,388.44 / $3,715.35
| Professional | | $2,754.23 | $3,388.44 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,467.37 / $4,365.16
| Professional | | $2,754.23 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $2,691.53 / $7,244.36
| Facility | | $489.78 | $2,691.53 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,235.94 / $20,417.38
| Professional | | $2,454.71 | $3,235.94 | $20,417.38 |
- 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
- $2,344.23 / $2,884.03 / $4,265.80
| Professional | | $2,344.23 | $2,884.03 | $4,265.80 |