- 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 / $1,621.81 / $3,090.30
| Professional | | $1,412.54 | $1,621.81 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,630.78 / $5,011.87
| Facility | | $3,090.30 | $3,630.78 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,238.72 / $2,630.27
| Professional | | $1,479.11 | $2,238.72 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $3,630.78
| Professional | | $1,202.26 | $1,905.46 | $3,630.78 |
- 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
- $1,174.90 / $1,659.59 / $2,570.40
| Professional | | $1,174.90 | $1,659.59 | $2,570.40 |