- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,495.41 / $7,762.47
| Facility | | $1,412.54 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,380.38 / $1,412.54
| Professional | | $812.83 | $1,380.38 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $17,378.01 / $35,481.34
| Professional | | $13,803.84 | $17,378.01 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,479.11 / $3,090.30
| Professional | | $1,380.38 | $1,479.11 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $63,095.73
| Facility | | $4,897.79 | $13,489.63 | $63,095.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,467.37
| Professional | | $1,258.93 | $1,819.70 | $3,467.37 |