- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,073.80 / $7,762.47
| Facility | | $1,380.38 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $2,041.74
| Professional | | $1,202.26 | $1,380.38 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,495.41 / $10,964.78
| Professional | | $1,318.26 | $5,495.41 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,380.38 / $3,715.35
| Professional | | $1,047.13 | $1,380.38 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,754.23 / $3,090.30
| Professional | | $1,288.25 | $2,754.23 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $35,481.34
| Facility | | $4,073.80 | $16,218.10 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $1,698.24 / $3,715.35
| Professional | | $645.65 | $1,698.24 | $3,715.35 |