- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,128.61 / $7,762.47
| Facility | | $1,584.89 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $4,365.16
| Professional | | $1,412.54 | $1,584.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,995.26 / $6,456.54
| Professional | | $1,621.81 | $1,995.26 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,238.72 / $4,265.80
| Professional | | $1,513.56 | $2,238.72 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,162.28 / $3,548.13
| Professional | | $1,479.11 | $3,162.28 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $13,489.63 / $26,915.35
| Facility | | $3,311.31 | $13,489.63 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $4,265.80
| Professional | | $1,288.25 | $2,041.74 | $4,265.80 |