- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $2,511.89 / $5,495.41
| Facility | | $2,511.89 | $2,511.89 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $2,454.71
| Professional | | $1,318.26 | $1,819.70 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,890.45 / $6,760.83
| Facility | | $794.33 | $3,890.45 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $812.83 / $2,754.23
| Professional | | $575.44 | $812.83 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $4,073.80 / $14,454.40
| Facility | | $1,621.81 | $4,073.80 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,677.35 / $5,495.41
| Professional | | $3,388.44 | $4,677.35 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $4,365.16
| Professional | | $1,202.26 | $1,513.56 | $4,365.16 |