- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,398.83
| Facility | | $1,096.48 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,905.46 / $3,467.37
| Professional | | $1,584.89 | $1,905.46 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,630.78 / $4,897.79
| Facility | | $3,019.95 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,454.71 / $2,818.38
| Professional | | $1,621.81 | $2,454.71 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $3,981.07
| Professional | | $1,479.11 | $2,238.72 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,818.38 / $4,073.80
| Facility | | $831.76 | $2,818.38 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $3,715.35
| Professional | | $1,348.96 | $1,862.09 | $3,715.35 |