- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,137.96 / $7,762.47
| Facility | | $1,659.59 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $2,238.72
| Professional | | $1,380.38 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,548.82 / $1,995.26
| Professional | | $1,380.38 | $1,548.82 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $3,981.07
| Professional | | $1,258.93 | $1,905.46 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,479.11 / $3,235.94
| Professional | | $1,412.54 | $1,479.11 | $3,235.94 |
- 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
- $1,230.27 / $1,659.59 / $3,467.37
| Professional | | $1,230.27 | $1,659.59 | $3,467.37 |