- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,344.23 / $7,762.47
| Facility | | $1,698.24 | $2,344.23 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $2,344.23 / $2,630.27
| Professional | | $1,230.27 | $2,344.23 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $5,128.61 / $9,120.11
| Professional | | $2,818.38 | $5,128.61 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,187.76 / $4,365.16
| Professional | | $2,089.30 | $2,187.76 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $35,481.34
| Facility | | $3,311.31 | $16,218.10 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $1,698.24 / $5,011.87
| Professional | | $407.38 | $1,698.24 | $5,011.87 |