- 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
- $1,778.28 / $2,290.87 / $3,311.31
| Professional | | $1,778.28 | $2,290.87 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,818.38 / $3,311.31
| Professional | | $2,137.96 | $2,818.38 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,570.40 / $6,309.57
| Facility | | $346.74 | $2,570.40 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,398.83 / $20,417.38
| Professional | | $1,778.28 | $2,398.83 | $20,417.38 |
- 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
- $1,737.80 / $2,187.76 / $3,467.37
| Professional | | $1,737.80 | $2,187.76 | $3,467.37 |