- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,630.27 / $6,606.93
| Facility | | $1,047.13 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $1,737.80
| Professional | | $870.96 | $1,023.29 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,230.27 / $1,445.44
| Professional | | $933.25 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,380.38 / $6,165.95
| Facility | | $489.78 | $1,380.38 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $6,918.31
| Professional | | $812.83 | $1,096.48 | $6,918.31 |
- 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
- $776.25 / $1,000.00 / $1,445.44
| Professional | | $776.25 | $1,000.00 | $1,445.44 |