- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,344.23
| Facility | | $1,096.48 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,621.81 / $2,754.23
| Professional | | $1,071.52 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,370.32 / $7,244.36
| Facility | | $4,466.84 | $5,370.32 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $4,466.84
| Professional | | $1,621.81 | $2,290.87 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,630.78 / $5,370.32
| Facility | | $1,122.02 | $3,630.78 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,096.48 / $1,479.11
| Professional | | $933.25 | $1,096.48 | $1,479.11 |