- 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
- $1,412.54 / $1,819.70 / $3,090.30
| Professional | | $1,412.54 | $1,819.70 | $3,090.30 |
- 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
- $1,479.11 / $2,089.30 / $2,511.89
| Professional | | $1,479.11 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,089.30 / $2,630.27
| Professional | | $1,148.15 | $2,089.30 | $2,630.27 |
- 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
- $1,148.15 / $1,621.81 / $2,398.83
| Professional | | $1,148.15 | $1,621.81 | $2,398.83 |