- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $2,754.23
| Facility | | $1,071.52 | $1,071.52 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,096.48 / $1,380.38
| Professional | | $1,023.29 | $1,096.48 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,090.30 / $3,467.37
| Professional | | $2,238.72 | $3,090.30 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $2,187.76
| Professional | | $1,778.28 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $912.01 / $1,174.90 / $2,754.23
| Facility | | $912.01 | $1,174.90 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,819.70 / $3,090.30
| Professional | | $645.65 | $1,819.70 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,584.89 / $2,630.27
| Professional | | $645.65 | $1,584.89 | $2,630.27 |