- 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
- $2,089.30 / $2,344.23 / $4,677.35
| Professional | | $2,089.30 | $2,344.23 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,630.78
| Professional | | $2,398.83 | $2,884.03 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $2,344.23 / $7,244.36
| Facility | | $489.78 | $2,344.23 | $7,244.36 |
- 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
- $1,995.26 / $2,454.71 / $3,548.13
| Professional | | $1,995.26 | $2,454.71 | $3,548.13 |