- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.71 / $1,372.49 / $1,608.75
| Facility | | $1,286.71 | $1,372.49 | $1,608.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,115.15 / $1,378.93 / $2,030.53
| Professional | | $1,115.15 | $1,378.93 | $2,030.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,292.62 / $2,648.27 / $4,871.88
| Facility | | $2,292.62 | $2,648.27 | $4,871.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.34 / $1,711.10 / $2,305.06
| Professional | | $1,458.34 | $1,711.10 | $2,305.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $1,800.00
| Facility | | $1,800.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.00 / $1,800.00 / $2,110.78
| Professional | | $1,314.00 | $1,800.00 | $2,110.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.05 / $1,405.43 / $1,900.09
| Professional | | $950.05 | $1,405.43 | $1,900.09 |