- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,137.96 / $7,762.47
| Facility | | $1,096.48 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,096.48 / $2,344.23
| Professional | | $1,023.29 | $1,096.48 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,398.83 / $6,025.60
| Professional | | $933.25 | $2,398.83 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,258.93 / $2,754.23
| Professional | | $977.24 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,187.76 / $2,398.83
| Professional | | $1,096.48 | $2,187.76 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $13,803.84 / $33,884.42
| Facility | | $4,073.80 | $13,803.84 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $2,691.53
| Professional | | $912.01 | $1,348.96 | $2,691.53 |