- 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
- $954.99 / $1,230.27 / $1,995.26
| Professional | | $954.99 | $1,230.27 | $1,995.26 |
- 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
- $1,023.29 / $1,445.44 / $1,698.24
| Professional | | $1,023.29 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,348.96 / $1,698.24
| Professional | | $776.25 | $1,348.96 | $1,698.24 |
- 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
- $741.31 / $1,096.48 / $1,584.89
| Professional | | $741.31 | $1,096.48 | $1,584.89 |