- 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
- $3,162.28 / $3,801.89 / $7,244.36
| Professional | | $3,162.28 | $3,801.89 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $8,128.31 / $10,964.78
| Facility | | $6,760.83 | $8,128.31 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $4,265.80 / $5,011.87
| Professional | | $2,754.23 | $4,265.80 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,748.98 / $14,125.38 / $16,982.44
| Professional | | $11,748.98 | $14,125.38 | $16,982.44 |
- 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
- $2,691.53 / $3,715.35 / $5,888.44
| Professional | | $2,691.53 | $3,715.35 | $5,888.44 |