- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $4,073.80 / $7,762.47
| Facility | | $1,479.11 | $4,073.80 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,412.54 / $3,890.45
| Professional | | $1,258.93 | $1,412.54 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $16,982.44
| Professional | | $1,380.38 | $2,398.83 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $3,981.07
| Professional | | $1,380.38 | $1,995.26 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,818.38 / $3,235.94
| Professional | | $1,380.38 | $2,818.38 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $35,481.34
| Facility | | $3,311.31 | $16,218.10 | $35,481.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,819.70 / $3,890.45
| Professional | | $1,122.02 | $1,819.70 | $3,890.45 |