- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,495.41 / $7,762.47
| Facility | | $1,584.89 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $1,949.84
| Professional | | $1,412.54 | $1,584.89 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $8,511.38 / $31,622.78
| Professional | | $1,513.56 | $8,511.38 | $31,622.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,344.23 / $4,265.80
| Professional | | $1,513.56 | $2,344.23 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $3,162.28 / $3,467.37
| Professional | | $1,445.44 | $3,162.28 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,120.11 / $25,703.96 / $63,095.73
| Facility | | $9,120.11 | $25,703.96 | $63,095.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $4,265.80
| Professional | | $1,380.38 | $2,041.74 | $4,265.80 |