- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,467.37 / $6,760.83
| Facility | | $1,202.26 | $3,467.37 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $7,585.78
| Professional | | $1,513.56 | $2,238.72 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $8,128.31 / $23,988.33
| Facility | | $1,737.80 | $8,128.31 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $27,542.29
| Professional | | $977.24 | $1,479.11 | $27,542.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $11,748.98 / $20,892.96
| Facility | | $3,467.37 | $11,748.98 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,258.93 / $2,238.72
| Professional | | $977.24 | $1,258.93 | $2,238.72 |