- 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
- $1,047.13 / $1,258.93 / $2,344.23
| Professional | | $1,047.13 | $1,258.93 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,709.64 / $10,471.29 / $14,125.38
| Facility | | $8,709.64 | $10,471.29 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,621.81 / $1,862.09
| Professional | | $1,071.52 | $1,621.81 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,412.54 / $2,754.23
| Professional | | $977.24 | $1,412.54 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $1,698.24 / $3,090.30
| Facility | | $630.96 | $1,698.24 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,202.26 / $1,905.46
| Professional | | $870.96 | $1,202.26 | $1,905.46 |