- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,137.96 / $7,762.47
| Facility | | $1,698.24 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $6,456.54
| Professional | | $1,862.09 | $2,137.96 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $6,918.31 / $15,135.61
| Professional | | $2,344.23 | $6,918.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,630.78 / $5,623.41
| Professional | | $2,041.74 | $3,630.78 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,265.80 / $4,677.35
| Professional | | $1,905.46 | $4,265.80 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $8,912.51 / $41,686.94
| Facility | | $4,897.79 | $8,912.51 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,754.23 / $5,623.41
| Professional | | $1,862.09 | $2,754.23 | $5,623.41 |