- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,918.31 / $11,748.98
| Facility | | $4,466.84 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $3,467.37
| Professional | | $1,862.09 | $1,862.09 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $794.33 / $1,023.29
| Professional | | $416.87 | $794.33 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $223.87 / $251.19
| Facility | | $109.65 | $223.87 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,548.82
| Professional | | $1,318.26 | $1,318.26 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $4,897.79 / $10,471.29
| Facility | | $1,318.26 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,943.28 / $7,943.28 / $8,128.31
| Professional | | $7,943.28 | $7,943.28 | $8,128.31 |