- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,698.24 / $2,511.89
| Facility | | $1,071.52 | $1,698.24 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $2,570.40
| Professional | | $1,548.82 | $1,905.46 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $7,079.46
| Facility | | $5,248.07 | $5,248.07 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $2,238.72
| Professional | | $1,698.24 | $1,698.24 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $2,884.03 / $3,235.94
| Professional | | $602.56 | $2,884.03 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $5,754.40 / $14,454.40
| Facility | | $2,187.76 | $5,754.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,041.74 / $3,467.37
| Professional | | $1,548.82 | $2,041.74 | $3,467.37 |