- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $7,244.36 / $9,772.37
| Facility | | $2,137.96 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,905.46 / $2,290.87
| Professional | | $1,174.90 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,549.93 / $12,589.25 / $19,952.62
| Professional | | $9,549.93 | $12,589.25 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,089.30 / $4,265.80
| Professional | | $1,778.28 | $2,089.30 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30,199.52 / $58,884.37 / $151,356.12
| Facility | | $30,199.52 | $58,884.37 | $151,356.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $5,495.41
| Professional | | $1,288.25 | $1,949.84 | $5,495.41 |