- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $15,488.17
| Facility | | $5,623.41 | $5,623.41 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,698.24 / $2,187.76
| Professional | | $1,202.26 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $4,265.80 / $12,589.25
| Facility | | $3,801.89 | $4,265.80 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $1,445.44 / $2,089.30
| Professional | | $512.86 | $1,445.44 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $6,918.31 / $9,549.93
| Facility | | $3,548.13 | $6,918.31 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $4,168.69
| Professional | | $2,187.76 | $2,187.76 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $2,187.76
| Professional | | $1,318.26 | $1,318.26 | $2,187.76 |