- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,884.03 / $6,606.93
| Facility | | $1,288.25 | $2,884.03 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,630.27 / $3,801.89
| Professional | | $2,041.74 | $2,630.27 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,548.13 / $4,168.69
| Professional | | $2,238.72 | $3,548.13 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,548.13 / $3,981.07
| Professional | | $2,454.71 | $3,548.13 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,884.03 / $6,309.57
| Facility | | $346.74 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,754.23 / $27,542.29
| Professional | | $2,041.74 | $2,754.23 | $27,542.29 |
- 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
- $1,949.84 / $2,570.40 / $3,981.07
| Professional | | $1,949.84 | $2,570.40 | $3,981.07 |