- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,073.80 / $6,456.54
| Facility | | $1,698.24 | $4,073.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,096.48 / $2,951.21
| Professional | | $1,047.13 | $1,096.48 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $2,398.83 / $10,715.19
| Professional | | $1,122.02 | $2,398.83 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,445.44 / $2,754.23
| Professional | | $1,023.29 | $1,445.44 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,238.72 / $2,454.71
| Professional | | $1,288.25 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $14,125.38 / $33,884.42
| Facility | | $4,073.80 | $14,125.38 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,445.44 / $2,951.21
| Professional | | $891.25 | $1,445.44 | $2,951.21 |