- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,137.96 / $7,762.47
| Facility | | $1,348.96 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,380.38 / $3,981.07
| Professional | | $1,318.26 | $1,380.38 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,479.11 / $1,949.84
| Professional | | $1,348.96 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,698.24 / $3,715.35
| Professional | | $1,318.26 | $1,698.24 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,258.93 / $2,884.03
| Professional | | $1,202.26 | $1,258.93 | $2,884.03 |
- 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
- $1,148.15 / $1,621.81 / $3,162.28
| Professional | | $1,148.15 | $1,621.81 | $3,162.28 |