- 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
- $1,905.46 / $2,238.72 / $3,801.89
| Professional | | $1,905.46 | $2,238.72 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,511.89 / $3,090.30
| Professional | | $1,737.80 | $2,511.89 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $2,398.83 / $7,244.36
| Facility | | $489.78 | $2,398.83 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,290.87 / $20,892.96
| Professional | | $1,698.24 | $2,290.87 | $20,892.96 |
- 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
- $1,659.59 / $2,041.74 / $3,090.30
| Professional | | $1,659.59 | $2,041.74 | $3,090.30 |