- 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
- $1,995.26 / $1,995.26 / $2,570.40
| Professional | | $1,995.26 | $1,995.26 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Professional | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $407.38 / $478.63
| Professional | | $288.40 | $407.38 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $1,995.26 / $4,073.80
| Facility | | $691.83 | $1,995.26 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $7,762.47 / $7,762.47
| Professional | | $2,187.76 | $7,762.47 | $7,762.47 |
- 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
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |