- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,073.80 / $7,762.47
| Facility | | $1,412.54 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,380.38 / $3,715.35
| Professional | | $1,202.26 | $1,380.38 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,445.44 / $2,818.38
| Professional | | $537.03 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,995.26 / $3,548.13
| Professional | | $1,288.25 | $1,995.26 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,818.38 / $3,090.30
| Professional | | $1,288.25 | $2,818.38 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $14,125.38 / $33,884.42
| Facility | | $4,073.80 | $14,125.38 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $3,715.35
| Professional | | $1,148.15 | $1,819.70 | $3,715.35 |