- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.83 / $1,213.83 / $1,566.62
| Facility | | $1,120.83 | $1,213.83 | $1,566.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.29 / $2,029.44 / $4,214.45
| Professional | | $1,536.29 | $2,029.44 | $4,214.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,961.06 / $3,547.68 / $4,271.50
| Professional | | $2,961.06 | $3,547.68 | $4,271.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,413.23 / $1,562.81 / $1,739.22
| Professional | | $1,413.23 | $1,562.81 | $1,739.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.14 / $968.68 / $1,830.63
| Professional | | $765.14 | $968.68 | $1,830.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.74 / $1,140.71 / $2,761.44
| Professional | | $842.74 | $1,140.71 | $2,761.44 |