- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,621.81 / $2,344.23
| Facility | | $1,230.27 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $1,995.26
| Professional | | $1,202.26 | $1,380.38 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,630.27 / $3,630.78
| Facility | | $2,630.27 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,862.09
| Professional | | $1,412.54 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $2,290.87
| Professional | | $1,202.26 | $1,659.59 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $1,445.44 / $5,248.07
| Facility | | $588.84 | $1,445.44 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,380.38 / $2,454.71
| Professional | | $1,096.48 | $1,380.38 | $2,454.71 |