- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,890.45 / $6,760.83
| Facility | | $1,202.26 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $6,918.31
| Professional | | $3,467.37 | $5,011.87 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $8,128.31 / $23,988.33
| Facility | | $3,235.94 | $8,128.31 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $42,657.95
| Professional | | $831.76 | $1,258.93 | $42,657.95 |
- 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
- $812.83 / $1,071.52 / $1,905.46
| Professional | | $812.83 | $1,071.52 | $1,905.46 |