- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,548.13 / $4,570.88
| Facility | | $1,445.44 | $3,548.13 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,288.25 / $2,951.21
| Professional | | $1,047.13 | $1,288.25 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,380.38 / $2,454.71
| Professional | | $1,122.02 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $3,235.94
| Professional | | $1,000.00 | $1,258.93 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,174.90 / $2,630.27
| Professional | | $1,023.29 | $1,174.90 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $1,737.80 / $5,128.61
| Facility | | $741.31 | $1,737.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $3,090.30
| Professional | | $831.76 | $1,174.90 | $3,090.30 |