- 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
- $851.14 / $1,096.48 / $1,862.09
| Professional | | $851.14 | $1,096.48 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $6,025.60 / $8,128.31
| Facility | | $5,011.87 | $6,025.60 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,318.26 / $1,548.82
| Professional | | $912.01 | $1,318.26 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,202.26 / $1,584.89
| Professional | | $691.83 | $1,202.26 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $5,370.32 / $8,511.38
| Facility | | $2,454.71 | $5,370.32 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $977.24 / $1,445.44
| Professional | | $676.08 | $977.24 | $1,445.44 |