- 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
- $1,258.93 / $1,584.89 / $2,754.23
| Professional | | $1,258.93 | $1,584.89 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $2,290.87
| Professional | | $1,513.56 | $1,949.84 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,905.46 / $6,165.95
| Facility | | $489.78 | $1,905.46 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $10,232.93
| Professional | | $1,318.26 | $1,737.80 | $10,232.93 |
- 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
- $1,258.93 / $1,584.89 / $2,398.83
| Professional | | $1,258.93 | $1,584.89 | $2,398.83 |