- 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
- $1,479.11 / $1,905.46 / $3,388.44
| Professional | | $1,479.11 | $1,905.46 | $3,388.44 |
- 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 / $2,187.76 / $2,691.53
| Professional | | $1,445.44 | $2,187.76 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $3,019.95
| Professional | | $1,380.38 | $2,089.30 | $3,019.95 |
- 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 / $1,659.59 / $2,630.27
| Professional | | $1,318.26 | $1,659.59 | $2,630.27 |