- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,128.61 / $15,488.17
| Facility | | $3,162.28 | $5,128.61 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,089.30 / $3,311.31
| Professional | | $1,513.56 | $2,089.30 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $5,370.32 / $7,413.10
| Facility | | $3,162.28 | $5,370.32 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $22,908.68
| Facility | | $1,949.84 | $5,495.41 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,019.95 / $3,019.95
| Facility | | $1,258.93 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,513.56 / $4,168.69
| Professional | | $1,258.93 | $1,513.56 | $4,168.69 |