- 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
- $1,380.38 / $1,905.46 / $2,398.83
| Professional | | $1,380.38 | $1,905.46 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $9,549.93 / $12,882.50
| Facility | | $8,128.31 | $9,549.93 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $512.86 / $1,258.93
| Professional | | $363.08 | $512.86 | $1,258.93 |
- 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
- $977.24 / $1,288.25 / $2,187.76
| Professional | | $977.24 | $1,288.25 | $2,187.76 |