- 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
- $1,202.26 / $1,778.28 / $2,570.40
| Professional | | $1,202.26 | $1,778.28 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,949.84 / $2,570.40
| Professional | | $1,412.54 | $1,949.84 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,995.26 / $6,309.57
| Facility | | $346.74 | $1,995.26 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,737.80 / $19,054.61
| Professional | | $1,288.25 | $1,737.80 | $19,054.61 |
- 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
- $1,230.27 / $1,479.11 / $2,691.53
| Professional | | $1,230.27 | $1,479.11 | $2,691.53 |