- 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
- $1,288.25 / $1,621.81 / $2,754.23
| Professional | | $1,288.25 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,995.26 / $2,344.23
| Professional | | $1,548.82 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,862.09 / $6,165.95
| Facility | | $489.78 | $1,862.09 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $10,715.19
| Professional | | $1,348.96 | $1,778.28 | $10,715.19 |
- 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
- $1,230.27 / $1,584.89 / $2,344.23
| Professional | | $1,230.27 | $1,584.89 | $2,344.23 |