- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,612.45 / $2,737.37 / $5,406.45
| Facility | | $1,612.45 | $2,737.37 | $5,406.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,327.90 / $1,536.57 / $1,821.12
| Professional | | $1,327.90 | $1,536.57 | $1,821.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,675.61 / $2,783.85 / $7,398.30
| Facility | | $1,675.61 | $2,783.85 | $7,398.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,147.68 / $1,549.20 / $2,453.01
| Professional | | $1,147.68 | $1,549.20 | $2,453.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,692.98 / $3,205.93 / $5,690.53
| Facility | | $1,692.98 | $3,205.93 | $5,690.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,311.04 / $2,311.04 / $2,768.89
| Professional | | $2,311.04 | $2,311.04 | $2,768.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,276.40 / $2,276.40 / $2,276.40
| Facility | | $2,276.40 | $2,276.40 | $2,276.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $796.74 / $1,138.20 / $2,276.40
| Professional | | $796.74 | $1,138.20 | $2,276.40 |