- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,890.45 / $6,456.54
| Facility | | $1,698.24 | $3,890.45 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $3,981.07
| Professional | | $1,122.02 | $1,548.82 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,398.83 / $7,943.28
| Professional | | $1,412.54 | $2,398.83 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,548.82 / $2,570.40
| Professional | | $1,230.27 | $1,548.82 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,090.30 / $3,388.44
| Professional | | $1,479.11 | $3,090.30 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $14,791.08 / $26,915.35
| Facility | | $3,311.31 | $14,791.08 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $3,311.31
| Professional | | $1,096.48 | $1,445.44 | $3,311.31 |