- 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
- $1,949.84 / $2,290.87 / $3,890.45
| Professional | | $1,949.84 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $2,884.03
| Professional | | $2,089.30 | $2,630.27 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $2,398.83 / $7,244.36
| Facility | | $489.78 | $2,398.83 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $15,488.17
| Professional | | $1,862.09 | $2,398.83 | $15,488.17 |
- 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
- $1,778.28 / $2,187.76 / $3,311.31
| Professional | | $1,778.28 | $2,187.76 | $3,311.31 |