- 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
- $1,174.90 / $1,445.44 / $2,630.27
| Professional | | $1,174.90 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $7,244.36 / $9,772.37
| Facility | | $6,165.95 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,089.30
| Professional | | $1,202.26 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,479.11 / $3,162.28
| Professional | | $1,023.29 | $1,479.11 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $6,918.31
| Facility | | $1,479.11 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $2,290.87
| Professional | | $1,047.13 | $1,348.96 | $2,290.87 |