- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,390.58 / $2,610.96 / $4,034.45
| Facility | | $1,390.58 | $2,610.96 | $4,034.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,010.82 / $1,099.27 / $1,351.98
| Professional | | $1,010.82 | $1,099.27 | $1,351.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,579.41 / $1,579.41 / $1,579.41
| Professional | | $1,579.41 | $1,579.41 | $1,579.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.95 / $2,069.65 / $2,865.33
| Facility | | $1,116.95 | $2,069.65 | $2,865.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,010.82 / $1,263.53 / $1,699.84
| Facility | | $1,010.82 | $1,263.53 | $1,699.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $758.12 / $6,292.38
| Professional | | $530.67 | $758.12 | $6,292.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $758.12 / $1,895.30
| Professional | | $530.67 | $758.12 | $1,895.30 |