- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,365.16 / $4,897.79
| Facility | | $1,202.26 | $4,365.16 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $1,412.54
| Professional | | $1,047.13 | $1,230.27 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $870.96
| Professional | | $691.83 | $691.83 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,089.30 / $2,511.89
| Facility | | $1,318.26 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,187.76 / $9,772.37
| Professional | | $1,148.15 | $2,187.76 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,089.30 / $3,548.13
| Professional | | $1,202.26 | $2,089.30 | $3,548.13 |