- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,398.83
| Facility | | $1,023.29 | $1,513.56 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $3,090.30
| Professional | | $1,412.54 | $1,659.59 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,025.60 / $7,244.36 / $9,772.37
| Facility | | $6,025.60 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $2,691.53
| Professional | | $1,513.56 | $2,089.30 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,819.70 / $3,630.78
| Professional | | $1,348.96 | $1,819.70 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,265.80 / $6,918.31
| Facility | | $1,202.26 | $4,265.80 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,621.81 / $2,818.38
| Professional | | $1,202.26 | $1,621.81 | $2,818.38 |