- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,884.03 / $6,606.93
| Facility | | $1,288.25 | $2,884.03 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,630.27 / $3,801.89
| Professional | | $1,513.56 | $2,630.27 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,398.83 / $3,548.13
| Professional | | $1,584.89 | $2,398.83 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,570.40 / $6,309.57
| Facility | | $346.74 | $2,570.40 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,570.40 / $16,595.87
| Professional | | $1,445.44 | $2,570.40 | $16,595.87 |
- 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
- $1,380.38 / $2,137.96 / $3,890.45
| Professional | | $1,380.38 | $2,137.96 | $3,890.45 |