- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,495.41 / $7,762.47
| Facility | | $1,380.38 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,318.26 / $1,380.38
| Professional | | $776.25 | $1,318.26 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $9,549.93 / $15,848.93
| Professional | | $5,623.41 | $9,549.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,174.90 / $3,019.95
| Professional | | $1,122.02 | $1,174.90 | $3,019.95 |
- 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
- $1,584.89 / $2,238.72 / $3,981.07
| Professional | | $1,584.89 | $2,238.72 | $3,981.07 |