- 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
- $1,513.56 / $1,698.24 / $3,311.31
| Professional | | $1,513.56 | $1,698.24 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $2,630.27
| Professional | | $1,698.24 | $2,089.30 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $1,949.84 / $6,165.95
| Facility | | $489.78 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,949.84 / $14,454.40
| Professional | | $1,513.56 | $1,949.84 | $14,454.40 |
- 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
- $1,412.54 / $1,778.28 / $2,570.40
| Professional | | $1,412.54 | $1,778.28 | $2,570.40 |