- 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
- $1,698.24 / $2,187.76 / $3,162.28
| Professional | | $1,698.24 | $2,187.76 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,884.03 / $3,162.28
| Professional | | $1,230.27 | $2,884.03 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,398.83 / $7,244.36
| Facility | | $346.74 | $2,398.83 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,511.89 / $13,803.84
| Professional | | $1,698.24 | $2,511.89 | $13,803.84 |
- 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
- $1,659.59 / $2,454.71 / $3,388.44
| Professional | | $1,659.59 | $2,454.71 | $3,388.44 |