- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $7,762.47
| Facility | | $1,698.24 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,584.89 / $2,511.89
| Professional | | $1,348.96 | $1,584.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,584.89 / $2,089.30
| Professional | | $1,148.15 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,698.24 / $4,073.80
| Professional | | $1,258.93 | $1,698.24 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,548.82 / $3,311.31
| Professional | | $1,445.44 | $1,548.82 | $3,311.31 |
- 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
- $1,148.15 / $1,548.82 / $3,630.78
| Professional | | $1,148.15 | $1,548.82 | $3,630.78 |