- 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
- $2,454.71 / $3,235.94 / $5,128.61
| Professional | | $2,454.71 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,128.31 / $9,772.37 / $13,182.57
| Facility | | $8,128.31 | $9,772.37 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,011.87 / $6,025.60
| Professional | | $3,630.78 | $5,011.87 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,235.94 / $5,248.07
| Professional | | $1,230.27 | $3,235.94 | $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
- $2,187.76 / $2,818.38 / $4,570.88
| Professional | | $2,187.76 | $2,818.38 | $4,570.88 |