- 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
- $1,445.44 / $1,862.09 / $3,890.45
| Professional | | $1,445.44 | $1,862.09 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,585.78 / $10,232.93
| Facility | | $6,456.54 | $7,585.78 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $2,511.89
| Professional | | $1,445.44 | $2,137.96 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $3,548.13
| Professional | | $1,380.38 | $2,089.30 | $3,548.13 |
- 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
- $1,258.93 / $1,621.81 / $2,818.38
| Professional | | $1,258.93 | $1,621.81 | $2,818.38 |