- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,137.96 / $7,762.47
| Facility | | $1,071.52 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $724.44 / $1,071.52
| Professional | | $575.44 | $724.44 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,548.13 / $6,165.95
| Professional | | $1,862.09 | $3,548.13 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,148.15 / $2,187.76
| Professional | | $1,096.48 | $1,148.15 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $16,218.10 / $33,884.42
| Facility | | $4,073.80 | $16,218.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $933.25 / $2,398.83
| Professional | | $660.69 | $933.25 | $2,398.83 |