- 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
- $1,778.28 / $2,187.76 / $4,073.80
| Professional | | $1,778.28 | $2,187.76 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,073.80 / $5,623.41
| Facility | | $3,467.37 | $4,073.80 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,398.83 / $2,818.38
| Professional | | $1,584.89 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,344.23 / $4,677.35
| Professional | | $1,659.59 | $2,344.23 | $4,677.35 |
- 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
- $1,513.56 / $2,089.30 / $3,388.44
| Professional | | $1,513.56 | $2,089.30 | $3,388.44 |