- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $5,495.41 / $7,762.47
| Facility | | $1,778.28 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,548.82 / $3,311.31
| Professional | | $1,174.90 | $1,548.82 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,548.82 / $4,897.79
| Professional | | $1,258.93 | $1,548.82 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $3,890.45
| Professional | | $1,122.02 | $1,412.54 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,513.56 / $3,162.28
| Professional | | $1,288.25 | $1,513.56 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $26,915.35
| Facility | | $3,311.31 | $16,218.10 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,348.96 / $3,630.78
| Professional | | $912.01 | $1,348.96 | $3,630.78 |