- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,995.26 / $6,606.93
| Facility | | $1,513.56 | $1,995.26 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,128.61 / $7,762.47
| Professional | | $4,365.16 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $537.03 / $562.34
| Facility | | $512.86 | $537.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,309.57 / $8,709.64
| Professional | | $3,630.78 | $6,309.57 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $758.58 / $2,570.40
| Facility | | $371.54 | $758.58 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,754.40 / $9,120.11
| Professional | | $4,265.80 | $5,754.40 | $9,120.11 |