- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,453.51 / $1,643.43 / $5,290.77
| Facility | | $1,453.51 | $1,643.43 | $5,290.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,453.51 / $1,511.65 / $1,841.11
| Professional | | $1,453.51 | $1,511.65 | $1,841.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,007.77 / $2,558.17 / $3,817.88
| Professional | | $1,007.77 | $2,558.17 | $3,817.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,323.73 / $4,175.52 / $6,920.28
| Facility | | $1,323.73 | $4,175.52 | $6,920.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,938.01 / $1,938.01 / $9,341.20
| Professional | | $1,938.01 | $1,938.01 | $9,341.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,372.14 / $9,205.54 / $9,205.54
| Facility | | $3,372.14 | $9,205.54 | $9,205.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,651.29 / $9,651.29 / $14,535.08
| Professional | | $9,651.29 | $9,651.29 | $14,535.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $813.96 / $1,162.81 / $1,938.01
| Professional | | $813.96 | $1,162.81 | $1,938.01 |