- 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
- $1,318.26 / $1,584.89 / $2,951.21
| Professional | | $1,318.26 | $1,584.89 | $2,951.21 |
- 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
- $1,348.96 / $1,995.26 / $2,344.23
| Professional | | $1,348.96 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,778.28 / $3,467.37
| Professional | | $1,148.15 | $1,778.28 | $3,467.37 |
- 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
- $1,122.02 / $1,513.56 / $2,398.83
| Professional | | $1,122.02 | $1,513.56 | $2,398.83 |