- 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
- $1,122.02 / $1,445.44 / $2,089.30
| Professional | | $1,122.02 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,905.46 / $2,137.96
| Professional | | $1,348.96 | $1,905.46 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,905.46 / $6,309.57
| Facility | | $346.74 | $1,905.46 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $10,715.19
| Professional | | $1,148.15 | $1,548.82 | $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
- $1,071.52 / $1,412.54 / $2,137.96
| Professional | | $1,071.52 | $1,412.54 | $2,137.96 |