- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,073.80 / $7,762.47
| Facility | | $1,479.11 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,380.38 / $2,238.72
| Professional | | $1,174.90 | $1,380.38 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,445.44 / $5,128.61
| Professional | | $1,258.93 | $1,445.44 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,445.44 / $3,715.35
| Professional | | $1,122.02 | $1,445.44 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,318.26 / $2,884.03
| Professional | | $1,258.93 | $1,318.26 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $25,118.86 / $33,884.42
| Facility | | $4,073.80 | $25,118.86 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $2,951.21
| Professional | | $1,023.29 | $1,412.54 | $2,951.21 |