- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $7,762.47
| Facility | | $3,467.37 | $3,467.37 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $3,388.44
| Professional | | $1,862.09 | $2,454.71 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,754.40 / $9,332.54
| Facility | | $4,365.16 | $5,754.40 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $794.33 / $3,801.89
| Professional | | $575.44 | $794.33 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $5,623.41 / $19,952.62
| Facility | | $2,290.87 | $5,623.41 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,309.57 / $7,585.78
| Professional | | $3,630.78 | $6,309.57 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $6,165.95
| Professional | | $1,659.59 | $2,089.30 | $6,165.95 |