- 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
- $1,737.80 / $2,238.72 / $3,235.94
| Professional | | $1,737.80 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,162.28
| Professional | | $2,398.83 | $2,884.03 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,951.21 / $3,388.44
| Professional | | $2,089.30 | $2,951.21 | $3,388.44 |
- 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
- $1,737.80 / $2,398.83 / $25,703.96
| Professional | | $1,737.80 | $2,398.83 | $25,703.96 |
- 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
- $1,659.59 / $2,187.76 / $3,388.44
| Professional | | $1,659.59 | $2,187.76 | $3,388.44 |