- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $7,244.36 / $9,772.37
| Facility | | $1,513.56 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,258.93 / $2,754.23
| Professional | | $1,096.48 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $5,011.87 / $13,803.84
| Professional | | $912.01 | $5,011.87 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,288.25 / $2,754.23
| Professional | | $954.99 | $1,288.25 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,023.29 / $2,398.83
| Professional | | $977.24 | $1,023.29 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,691.53
| Professional | | $870.96 | $1,230.27 | $2,691.53 |