- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,137.96 / $7,762.47
| Facility | | $1,258.93 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,288.25 / $3,715.35
| Professional | | $1,202.26 | $1,288.25 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,445.44 / $1,778.28
| Professional | | $1,318.26 | $1,445.44 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $3,388.44
| Professional | | $1,230.27 | $1,548.82 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,148.15 / $2,630.27
| Professional | | $1,096.48 | $1,148.15 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $2,344.23 / $16,218.10
| Facility | | $645.65 | $2,344.23 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,884.03
| Professional | | $1,047.13 | $1,479.11 | $2,884.03 |