- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,128.61 / $7,762.47
| Facility | | $1,380.38 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,380.38 / $4,073.80
| Professional | | $1,230.27 | $1,380.38 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,715.35 / $10,715.19
| Professional | | $1,513.56 | $3,715.35 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,862.09 / $3,715.35
| Professional | | $1,318.26 | $1,862.09 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,884.03 / $3,019.95
| Professional | | $1,288.25 | $2,884.03 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $3,715.35
| Professional | | $1,202.26 | $1,778.28 | $3,715.35 |