- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,778.28 / $2,454.71
| Facility | | $1,513.56 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,348.96 / $1,949.84
| Professional | | $1,202.26 | $1,348.96 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,165.95 / $6,165.95 / $8,511.38
| Facility | | $6,165.95 | $6,165.95 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,862.09
| Professional | | $1,412.54 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,995.26 / $2,344.23
| Professional | | $1,096.48 | $1,995.26 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,073.80 / $11,748.98
| Facility | | $1,548.82 | $4,073.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,584.89 / $2,511.89
| Professional | | $1,230.27 | $1,584.89 | $2,511.89 |