- 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
- $1,513.56 / $1,949.84 / $3,162.28
| Professional | | $1,513.56 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $6,309.57 / $8,511.38
| Facility | | $5,248.07 | $6,309.57 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,089.30 / $2,691.53
| Professional | | $1,445.44 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $3,090.30
| Professional | | $1,412.54 | $2,089.30 | $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
- $1,318.26 / $1,698.24 / $2,691.53
| Professional | | $1,318.26 | $1,698.24 | $2,691.53 |