- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,128.61 / $7,762.47
| Facility | | $1,445.44 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,412.54 / $3,715.35
| Professional | | $1,148.15 | $1,412.54 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,715.35 / $10,715.19
| Professional | | $1,479.11 | $3,715.35 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,778.28 / $3,890.45
| Professional | | $1,412.54 | $1,778.28 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,884.03 / $3,235.94
| Professional | | $1,318.26 | $2,884.03 | $3,235.94 |
- 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
- $1,096.48 / $1,778.28 / $3,890.45
| Professional | | $1,096.48 | $1,778.28 | $3,890.45 |