- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,128.61 / $7,762.47
| Facility | | $1,621.81 | $5,128.61 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,621.81 / $4,570.88
| Professional | | $1,445.44 | $1,621.81 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,715.35 / $10,715.19
| Professional | | $1,621.81 | $3,715.35 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,238.72 / $4,365.16
| Professional | | $1,548.82 | $2,238.72 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,467.37 / $3,548.13
| Professional | | $1,513.56 | $3,467.37 | $3,548.13 |
- 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
- $1,318.26 / $2,089.30 / $4,365.16
| Professional | | $1,318.26 | $2,089.30 | $4,365.16 |