- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $5,011.87 / $7,762.47
| Facility | | $2,137.96 | $5,011.87 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $5,248.07 / $6,760.83
| Professional | | $1,148.15 | $5,248.07 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $2,137.96 / $15,848.93
| Professional | | $776.25 | $2,137.96 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $13,182.57
| Professional | | $2,344.23 | $2,344.23 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $25,703.96 / $57,543.99
| Facility | | $9,120.11 | $25,703.96 | $57,543.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $1,513.56 / $20,417.38
| Professional | | $660.69 | $1,513.56 | $20,417.38 |