- 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
- $1,513.56 / $1,819.70 / $3,019.95
| Professional | | $1,513.56 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,995.26 / $6,456.54
| Facility | | $891.25 | $1,995.26 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,187.76 / $11,481.54
| Professional | | $1,445.44 | $2,187.76 | $11,481.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,311.31 / $6,025.60
| Facility | | $891.25 | $3,311.31 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,137.96 / $2,951.21
| Professional | | $1,584.89 | $2,137.96 | $2,951.21 |