- 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
- $977.24 / $1,288.25 / $1,862.09
| Professional | | $977.24 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,737.80 / $1,995.26
| Professional | | $1,202.26 | $1,737.80 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,778.28 / $6,309.57
| Facility | | $346.74 | $1,778.28 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $11,748.98
| Professional | | $1,023.29 | $1,412.54 | $11,748.98 |
- 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
- $977.24 / $1,288.25 / $1,905.46
| Professional | | $977.24 | $1,288.25 | $1,905.46 |