- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $5,495.41 / $7,762.47
| Facility | | $1,202.26 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,202.26 / $2,754.23
| Professional | | $1,023.29 | $1,202.26 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $6,918.31 / $15,135.61
| Professional | | $1,202.26 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $3,235.94
| Professional | | $1,148.15 | $1,380.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,344.23 / $2,691.53
| Professional | | $1,258.93 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $3,235.94
| Professional | | $831.76 | $1,412.54 | $3,235.94 |