- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,168.69 / $6,456.54
| Facility | | $1,737.80 | $4,168.69 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $4,677.35
| Professional | | $1,513.56 | $1,737.80 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,454.71 / $17,378.01
| Professional | | $1,659.59 | $2,454.71 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,570.40 / $4,570.88
| Professional | | $1,659.59 | $2,570.40 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $3,467.37 / $3,801.89
| Professional | | $1,584.89 | $3,467.37 | $3,801.89 |
- 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
- $1,412.54 / $2,238.72 / $4,570.88
| Professional | | $1,412.54 | $2,238.72 | $4,570.88 |