- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,691.53 / $6,606.93
| Facility | | $1,288.25 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,398.83 / $3,548.13
| Professional | | $1,862.09 | $2,398.83 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $3,548.13
| Professional | | $2,290.87 | $3,235.94 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,754.23 / $6,309.57
| Facility | | $346.74 | $2,754.23 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,511.89 / $24,547.09
| Professional | | $1,949.84 | $2,511.89 | $24,547.09 |
- 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
- $1,862.09 / $2,398.83 / $3,630.78
| Professional | | $1,862.09 | $2,398.83 | $3,630.78 |