- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,630.27 / $6,606.93
| Facility | | $1,230.27 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $2,089.30
| Professional | | $1,047.13 | $1,230.27 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,479.11 / $1,737.80
| Professional | | $1,122.02 | $1,479.11 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,513.56 / $6,165.95
| Facility | | $489.78 | $1,513.56 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,288.25 / $8,511.38
| Professional | | $977.24 | $1,288.25 | $8,511.38 |
- 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
- $933.25 / $1,174.90 / $1,737.80
| Professional | | $933.25 | $1,174.90 | $1,737.80 |