- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,137.96 / $7,762.47
| Facility | | $1,621.81 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,621.81 / $4,168.69
| Professional | | $1,548.82 | $1,621.81 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $2,344.23
| Professional | | $1,202.26 | $1,348.96 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,137.96 / $4,073.80
| Professional | | $1,479.11 | $2,137.96 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,311.31 / $3,630.78
| Professional | | $1,621.81 | $3,311.31 | $3,630.78 |
- 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
- $1,380.38 / $2,041.74 / $4,073.80
| Professional | | $1,380.38 | $2,041.74 | $4,073.80 |