- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,011.87 / $10,471.29
| Facility | | $3,467.37 | $5,011.87 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $3,388.44
| Professional | | $1,905.46 | $2,570.40 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,495.41 / $9,549.93
| Facility | | $3,801.89 | $5,495.41 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $2,290.87 / $7,762.47
| Professional | | $239.88 | $2,290.87 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,677.35 / $12,882.50
| Facility | | $2,290.87 | $4,677.35 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,456.54 / $7,585.78
| Professional | | $4,677.35 | $6,456.54 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,089.30 / $6,165.95
| Professional | | $1,698.24 | $2,089.30 | $6,165.95 |