- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $7,762.47
| Facility | | $1,548.82 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,187.76
| Professional | | $1,202.26 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,445.44 / $1,905.46
| Professional | | $1,288.25 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $3,715.35
| Professional | | $1,148.15 | $1,513.56 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,380.38 / $3,019.95
| Professional | | $1,318.26 | $1,380.38 | $3,019.95 |
- 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
- $1,071.52 / $1,445.44 / $3,235.94
| Professional | | $1,071.52 | $1,445.44 | $3,235.94 |