- 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
- $1,621.81 / $2,137.96 / $3,019.95
| Professional | | $1,621.81 | $2,137.96 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $3,388.44
| Professional | | $1,995.26 | $2,884.03 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,454.71 / $6,309.57
| Facility | | $346.74 | $2,454.71 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $13,182.57
| Professional | | $1,698.24 | $2,344.23 | $13,182.57 |
- 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 / $2,137.96 / $3,162.28
| Professional | | $1,659.59 | $2,137.96 | $3,162.28 |