- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,088.94 / $4,031.64 / $18,607.25
| Facility | | $1,088.94 | $4,031.64 | $18,607.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $1,730.32 / $1,730.32
| Professional | | $1,730.32 | $1,730.32 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.32 / $2,605.65 / $4,405.91
| Professional | | $1,730.32 | $2,605.65 | $4,405.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,632.38 / $1,632.38 / $1,730.32
| Facility | | $1,632.38 | $1,632.38 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,470.77 / $1,470.77 / $1,730.32
| Professional | | $1,470.77 | $1,470.77 | $1,730.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,713.02 / $1,955.26 / $2,547.07
| Professional | | $1,713.02 | $1,955.26 | $2,547.07 |