- 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
- $1,148.15 / $1,513.56 / $2,570.40
| Professional | | $1,148.15 | $1,513.56 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,128.31 / $10,964.78
| Facility | | $6,760.83 | $8,128.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $2,089.30
| Professional | | $1,230.27 | $1,778.28 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,737.80 / $2,089.30
| Professional | | $954.99 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,659.59 / $5,248.07
| Facility | | $660.69 | $1,659.59 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $1,949.84
| Professional | | $891.25 | $1,318.26 | $1,949.84 |