- 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
- $537.03 / $1,047.13 / $2,089.30
| Professional | | $537.03 | $1,047.13 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,862.09 / $5,754.40
| Facility | | $891.25 | $1,862.09 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $2,137.96 / $7,079.46
| Professional | | $660.69 | $2,137.96 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $3,311.31 / $6,025.60
| Facility | | $891.25 | $3,311.31 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,089.30 / $2,951.21
| Professional | | $1,584.89 | $2,089.30 | $2,951.21 |