- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,025.60 / $16,982.44
| Facility | | $3,162.28 | $6,025.60 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $4,570.88
| Professional | | $2,818.38 | $2,818.38 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $12,022.64 / $19,952.62
| Facility | | $9,772.37 | $12,022.64 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $44.67 / $60.26
| Professional | | $44.67 | $44.67 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,148.15 / $1,202.26
| Professional | | $1,148.15 | $1,148.15 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,128.61 / $13,803.84
| Facility | | $2,290.87 | $5,128.61 | $13,803.84 |