- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,264.10 / $4,592.00 / $6,915.00
| Facility | | $1,264.10 | $4,592.00 | $6,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,206.41 / $1,250.68 / $1,284.67
| Professional | | $1,206.41 | $1,250.68 | $1,284.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,491.93 / $4,469.68 / $9,523.08
| Facility | | $1,491.93 | $4,469.68 | $9,523.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.02 / $56.55 / $56.55
| Professional | | $52.02 | $56.55 | $56.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,200.00 / $4,826.00 / $7,889.00
| Facility | | $1,200.00 | $4,826.00 | $7,889.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.61 / $2,092.35 / $3,542.96
| Professional | | $1,448.61 | $2,092.35 | $3,542.96 |