- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,630.27 / $6,606.93
| Facility | | $1,230.27 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,122.02 / $1,621.81
| Professional | | $870.96 | $1,122.02 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $1,584.89
| Professional | | $1,047.13 | $1,380.38 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,513.56 / $6,309.57
| Facility | | $346.74 | $1,513.56 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,148.15 / $7,079.46
| Professional | | $851.14 | $1,148.15 | $7,079.46 |
- 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
- $831.76 / $1,047.13 / $1,659.59
| Professional | | $831.76 | $1,047.13 | $1,659.59 |