- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,128.61 / $7,762.47
| Facility | | $1,621.81 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $4,466.84
| Professional | | $1,412.54 | $1,621.81 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,862.09 / $11,748.98
| Professional | | $537.03 | $1,862.09 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,454.71 / $4,365.16
| Professional | | $1,584.89 | $2,454.71 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,388.44 / $3,548.13
| Professional | | $1,479.11 | $3,388.44 | $3,548.13 |
- 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
- $1,318.26 / $2,089.30 / $4,365.16
| Professional | | $1,318.26 | $2,089.30 | $4,365.16 |