- 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
- $1,548.82 / $1,949.84 / $3,467.37
| Professional | | $1,548.82 | $1,949.84 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,398.83 / $2,884.03
| Professional | | $1,905.46 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $2,137.96 / $6,309.57
| Facility | | $489.78 | $2,137.96 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,089.30 / $15,135.61
| Professional | | $1,621.81 | $2,089.30 | $15,135.61 |
- 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
- $1,513.56 / $1,949.84 / $2,884.03
| Professional | | $1,513.56 | $1,949.84 | $2,884.03 |