- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,818.38 / $6,606.93
| Facility | | $1,288.25 | $2,818.38 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $3,715.35
| Professional | | $1,995.26 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $3,801.89
| Professional | | $2,398.83 | $3,467.37 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,818.38 / $6,309.57
| Facility | | $346.74 | $2,818.38 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,691.53 / $30,902.95
| Professional | | $2,041.74 | $2,691.53 | $30,902.95 |
- 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 / $2,511.89 / $3,890.45
| Professional | | $1,949.84 | $2,511.89 | $3,890.45 |