- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,584.89 / $2,754.23
| Facility | | $1,174.90 | $1,584.89 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $2,754.23
| Professional | | $1,202.26 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,659.59 / $6,606.93
| Facility | | $1,230.27 | $1,659.59 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,659.59 / $3,630.78
| Professional | | $1,621.81 | $1,659.59 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $13,489.63
| Facility | | $2,290.87 | $2,290.87 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,659.59 / $4,786.30
| Professional | | $1,659.59 | $1,659.59 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,041.74 / $3,630.78
| Facility | | $1,318.26 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $2,238.72
| Professional | | $1,096.48 | $1,513.56 | $2,238.72 |