- 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
- $1,288.25 / $1,584.89 / $2,570.40
| Professional | | $1,288.25 | $1,584.89 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,778.28 / $2,454.71
| Professional | | $977.24 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,778.28 / $5,248.07
| Facility | | $1,023.29 | $1,778.28 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,698.24 / $10,471.29
| Professional | | $1,288.25 | $1,698.24 | $10,471.29 |
- 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
- $1,202.26 / $1,548.82 / $2,290.87
| Professional | | $1,202.26 | $1,548.82 | $2,290.87 |