- 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
- $1,412.54 / $1,819.70 / $2,630.27
| Professional | | $1,412.54 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,398.83 / $2,630.27
| Professional | | $1,698.24 | $2,398.83 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,089.30 / $6,309.57
| Facility | | $346.74 | $2,089.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $11,481.54
| Professional | | $1,412.54 | $1,905.46 | $11,481.54 |
- 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
- $1,348.96 / $1,737.80 / $2,691.53
| Professional | | $1,348.96 | $1,737.80 | $2,691.53 |