- 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
- $1,737.80 / $2,187.76 / $3,630.78
| Professional | | $1,737.80 | $2,187.76 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $10,471.29 / $14,125.38
| Facility | | $8,709.64 | $10,471.29 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $2,951.21
| Professional | | $1,621.81 | $2,290.87 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,344.23 / $3,388.44
| Professional | | $1,621.81 | $2,344.23 | $3,388.44 |
- 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
- $1,445.44 / $1,905.46 / $3,090.30
| Professional | | $1,445.44 | $1,905.46 | $3,090.30 |