- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,265.17 / $1,519.92 / $2,380.67
| Facility | | $1,265.17 | $1,519.92 | $2,380.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.17 / $1,614.85 / $2,795.48
| Professional | | $1,265.17 | $1,614.85 | $2,795.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,274.96 / $1,386.31 / $1,666.90
| Facility | | $1,274.96 | $1,386.31 | $1,666.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.06 / $1,481.69 / $1,481.69
| Professional | | $916.06 | $1,481.69 | $1,481.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,222.92 / $2,222.92 / $2,222.92
| Facility | | $2,222.92 | $2,222.92 | $2,222.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,372.65 / $2,306.27 / $5,301.90
| Professional | | $1,372.65 | $2,306.27 | $5,301.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,305.71 / $2,041.71 / $3,025.18
| Professional | | $1,305.71 | $2,041.71 | $3,025.18 |