- 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
- $1,584.89 / $1,905.46 / $3,162.28
| Professional | | $1,584.89 | $1,905.46 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,187.76 / $3,019.95
| Professional | | $1,202.26 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,137.96 / $5,370.32
| Facility | | $1,096.48 | $2,137.96 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,089.30 / $12,882.50
| Professional | | $1,621.81 | $2,089.30 | $12,882.50 |
- 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
- $1,513.56 / $1,905.46 / $2,818.38
| Professional | | $1,513.56 | $1,905.46 | $2,818.38 |