- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,818.38 / $7,762.47
| Facility | | $1,698.24 | $2,818.38 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,818.38 / $6,760.83
| Professional | | $2,454.71 | $2,818.38 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $15,488.17 / $31,622.78
| Professional | | $2,884.03 | $15,488.17 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,890.45 / $7,585.78
| Professional | | $2,691.53 | $3,890.45 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $5,623.41 / $6,165.95
| Professional | | $2,570.40 | $5,623.41 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $25,703.96 / $87,096.36
| Facility | | $9,120.11 | $25,703.96 | $87,096.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,630.78 / $7,585.78
| Professional | | $1,995.26 | $3,630.78 | $7,585.78 |