- 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
- $1,202.26 / $1,412.54 / $2,630.27
| Professional | | $1,202.26 | $1,412.54 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,248.07 / $7,079.46
| Facility | | $4,466.84 | $5,248.07 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,548.82 / $1,905.46
| Professional | | $1,047.13 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $3,090.30
| Professional | | $1,096.48 | $1,548.82 | $3,090.30 |
- 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
- $1,000.00 / $1,380.38 / $2,187.76
| Professional | | $1,000.00 | $1,380.38 | $2,187.76 |