- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,630.27 / $6,606.93
| Facility | | $1,023.29 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $1,949.84
| Professional | | $1,258.93 | $1,548.82 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,862.09 / $6,456.54
| Facility | | $891.25 | $1,862.09 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $8,709.64
| Professional | | $1,412.54 | $1,862.09 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,311.31 / $6,165.95
| Facility | | $891.25 | $3,311.31 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $2,511.89
| Professional | | $1,348.96 | $1,778.28 | $2,511.89 |