- 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
- $2,041.74 / $2,398.83 / $4,466.84
| Professional | | $2,041.74 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,606.93 / $8,912.51
| Facility | | $5,623.41 | $6,606.93 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,235.94 / $3,801.89
| Professional | | $2,137.96 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,754.23 / $5,248.07
| Professional | | $1,905.46 | $2,754.23 | $5,248.07 |
- 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
- $1,737.80 / $2,398.83 / $3,890.45
| Professional | | $1,737.80 | $2,398.83 | $3,890.45 |