- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,495.41 / $7,762.47
| Facility | | $2,041.74 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,949.84 / $2,041.74
| Professional | | $1,258.93 | $1,949.84 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,495.41 / $10,715.19
| Professional | | $1,862.09 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,089.30 / $4,466.84
| Professional | | $1,445.44 | $2,089.30 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,659.59 / $3,890.45
| Professional | | $1,584.89 | $1,659.59 | $3,890.45 |
- 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
- $1,479.11 / $1,995.26 / $4,365.16
| Professional | | $1,479.11 | $1,995.26 | $4,365.16 |