- 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
- $1,047.13 / $1,348.96 / $1,949.84
| Professional | | $1,047.13 | $1,348.96 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,862.09 / $2,187.76
| Professional | | $1,174.90 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,862.09 / $2,187.76
| Professional | | $1,288.25 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,862.09 / $6,309.57
| Facility | | $346.74 | $1,862.09 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,479.11 / $10,715.19
| Professional | | $1,071.52 | $1,479.11 | $10,715.19 |
- 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
- $1,047.13 / $1,380.38 / $2,041.74
| Professional | | $1,047.13 | $1,380.38 | $2,041.74 |