- 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
- $1,258.93 / $1,445.44 / $2,290.87
| Professional | | $1,258.93 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,445.44 / $1,862.09
| Professional | | $1,288.25 | $1,445.44 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $3,715.35
| Professional | | $1,258.93 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,412.54 / $3,019.95
| Professional | | $1,348.96 | $1,412.54 | $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 / $1,513.56 / $3,235.94
| Professional | | $1,071.52 | $1,513.56 | $3,235.94 |