- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $5,495.41 / $7,762.47
| Facility | | $1,819.70 | $5,495.41 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $4,365.16
| Professional | | $1,584.89 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,548.13 / $13,803.84
| Professional | | $1,819.70 | $3,548.13 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,819.70 / $4,897.79
| Professional | | $1,621.81 | $1,819.70 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,630.78 / $3,981.07
| Professional | | $1,659.59 | $3,630.78 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $13,489.63 / $41,686.94
| Facility | | $4,897.79 | $13,489.63 | $41,686.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $2,238.72 / $4,897.79
| Professional | | $933.25 | $2,238.72 | $4,897.79 |