- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,162.28 / $7,762.47
| Facility | | $1,258.93 | $3,162.28 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,288.25 / $3,235.94
| Professional | | $1,071.52 | $1,288.25 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,071.52 / $1,778.28
| Professional | | $537.03 | $1,071.52 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,412.54 / $3,467.37
| Professional | | $1,096.48 | $1,412.54 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,202.26 / $2,630.27
| Professional | | $1,148.15 | $1,202.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $758.58 / $5,128.61
| Facility | | $354.81 | $758.58 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $2,884.03
| Professional | | $1,047.13 | $1,380.38 | $2,884.03 |