- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,374.93 / $1,442.63 / $1,618.90
| Facility | | $1,374.93 | $1,442.63 | $1,618.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.74 / $1,442.63 / $1,850.85
| Professional | | $1,191.74 | $1,442.63 | $1,850.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.68 / $1,790.31 / $1,790.31
| Professional | | $1,352.68 | $1,790.31 | $1,790.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,060.00 / $1,731.42 / $2,224.04
| Professional | | $1,060.00 | $1,731.42 | $2,224.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $1,056.00 / $2,558.00
| Facility | | $375.00 | $1,056.00 | $2,558.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,070.32 / $1,375.74 / $2,389.30
| Professional | | $1,070.32 | $1,375.74 | $2,389.30 |