- 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
- $1,148.15 / $1,348.96 / $2,290.87
| Professional | | $1,148.15 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $5,754.40 / $7,762.47
| Facility | | $4,786.30 | $5,754.40 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $1,949.84
| Professional | | $1,047.13 | $1,479.11 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,288.25 / $2,137.96
| Professional | | $758.58 | $1,288.25 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $6,918.31
| Facility | | $1,479.11 | $4,365.16 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,148.15 / $1,862.09
| Professional | | $891.25 | $1,148.15 | $1,862.09 |