- 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
- $1,202.26 / $1,445.44 / $2,691.53
| Professional | | $1,202.26 | $1,445.44 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,549.93 / $11,481.54 / $15,488.17
| Facility | | $9,549.93 | $11,481.54 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $2,511.89
| Professional | | $1,479.11 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,778.28 / $3,162.28
| Professional | | $1,122.02 | $1,778.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $660.69 / $1,659.59 / $5,248.07
| Facility | | $660.69 | $1,659.59 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,513.56 / $2,691.53
| Professional | | $1,023.29 | $1,513.56 | $2,691.53 |