- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,630.27
| Facility | | $1,096.48 | $1,659.59 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $2,754.23
| Professional | | $1,071.52 | $1,412.54 | $2,754.23 |
- 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
- $912.01 / $1,288.25 / $1,819.70
| Professional | | $912.01 | $1,288.25 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $2,290.87
| Professional | | $912.01 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,365.16 / $6,606.93
| Facility | | $1,479.11 | $4,365.16 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,288.25 / $1,995.26
| Professional | | $954.99 | $1,288.25 | $1,995.26 |