- 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
- $2,041.74 / $2,454.71 / $3,890.45
| Professional | | $2,041.74 | $2,454.71 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,019.95 / $3,890.45
| Professional | | $2,238.72 | $3,019.95 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,818.38 / $3,890.45
| Professional | | $1,445.44 | $2,818.38 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,691.53 / $5,754.40
| Facility | | $1,096.48 | $2,691.53 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,691.53 / $16,595.87
| Professional | | $2,089.30 | $2,691.53 | $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
- $1,949.84 / $2,454.71 / $3,630.78
| Professional | | $1,949.84 | $2,454.71 | $3,630.78 |