- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $7,244.36 / $9,772.37
| Facility | | $2,041.74 | $7,244.36 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $3,890.45
| Professional | | $1,380.38 | $1,737.80 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,630.78 / $11,748.98
| Professional | | $1,479.11 | $3,630.78 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,659.59 / $4,466.84
| Professional | | $1,348.96 | $1,659.59 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,659.59 / $3,630.78
| Professional | | $1,445.44 | $1,659.59 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $16,218.10 / $26,915.35
| Facility | | $3,311.31 | $16,218.10 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $4,168.69
| Professional | | $1,122.02 | $1,548.82 | $4,168.69 |