- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,651.22 / $3,054.76 / $6,186.55
| Facility | | $1,651.22 | $3,054.76 | $6,186.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,651.22 / $1,739.28 / $1,871.38
| Professional | | $1,651.22 | $1,739.28 | $1,871.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.83 / $1,651.22 / $3,522.59
| Professional | | $1,144.83 | $1,651.22 | $3,522.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,452.52 / $4,532.37 / $9,786.70
| Facility | | $1,452.52 | $4,532.37 | $9,786.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,201.69 / $2,529.63 / $3,162.03
| Professional | | $2,201.69 | $2,529.63 | $3,162.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,830.82 / $10,457.70 / $10,457.70
| Facility | | $3,830.82 | $10,457.70 | $10,457.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $924.68 / $1,320.97 / $2,201.62
| Professional | | $924.68 | $1,320.97 | $2,201.62 |