- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $7,762.47
| Facility | | $1,621.81 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $2,398.83
| Professional | | $1,288.25 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,513.56 / $1,995.26
| Professional | | $1,348.96 | $1,513.56 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,584.89 / $3,890.45
| Professional | | $1,202.26 | $1,584.89 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,445.44 / $3,162.28
| Professional | | $1,348.96 | $1,445.44 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,290.87 / $6,309.57
| Facility | | $645.65 | $2,290.87 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,513.56 / $3,388.44
| Professional | | $1,122.02 | $1,513.56 | $3,388.44 |