- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,202.26 / $21,877.62
| Facility | | $1,174.90 | $1,202.26 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,174.90 / $1,659.59
| Professional | | $933.25 | $1,174.90 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,630.27 / $3,311.31
| Professional | | $2,290.87 | $2,630.27 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,290.87 / $3,162.28
| Professional | | $1,819.70 | $2,290.87 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,949.84 / $3,630.78
| Facility | | $1,202.26 | $1,949.84 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,801.89 / $17,378.01
| Professional | | $2,041.74 | $3,801.89 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,398.83 / $5,248.07
| Professional | | $1,202.26 | $2,398.83 | $5,248.07 |