- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,128.61 / $7,762.47
| Facility | | $1,862.09 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,862.09 / $5,754.40
| Professional | | $1,659.59 | $1,862.09 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,715.35 / $10,715.19
| Professional | | $2,041.74 | $3,715.35 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,884.03 / $5,011.87
| Professional | | $1,819.70 | $2,884.03 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,715.35 / $4,073.80
| Professional | | $1,621.81 | $3,715.35 | $4,073.80 |
- 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
- $1,621.81 / $2,398.83 / $5,011.87
| Professional | | $1,621.81 | $2,398.83 | $5,011.87 |