- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $6,456.54 / $21,877.62
| Facility | | $3,162.28 | $6,456.54 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $2,511.89
| Professional | | $1,348.96 | $1,862.09 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $1,949.84 / $7,943.28
| Facility | | $851.14 | $1,949.84 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,479.11 / $44,668.36
| Professional | | $1,096.48 | $1,479.11 | $44,668.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $1,230.27 / $5,623.41
| Facility | | $478.63 | $1,230.27 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,162.28
| Professional | | $1,047.13 | $1,513.56 | $3,162.28 |