- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,073.80 / $7,762.47
| Facility | | $1,513.56 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,513.56 / $1,621.81
| Professional | | $1,318.26 | $1,513.56 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,778.28 / $3,311.31
| Professional | | $1,659.59 | $1,778.28 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,691.53 / $66,069.34
| Facility | | $1,023.29 | $2,691.53 | $66,069.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $3,981.07
| Professional | | $1,258.93 | $1,862.09 | $3,981.07 |