- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $4,897.79
| Facility | | $2,238.72 | $2,238.72 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,445.44 / $2,137.96
| Professional | | $1,202.26 | $1,445.44 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $6,025.60
| Facility | | $2,754.23 | $3,715.35 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,548.82 / $4,265.80
| Professional | | $1,348.96 | $1,548.82 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $12,882.50
| Facility | | $1,445.44 | $1,445.44 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,162.28
| Professional | | $2,570.40 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,047.13 / $1,318.26
| Professional | | $1,047.13 | $1,047.13 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,659.59 / $3,890.45
| Professional | | $933.25 | $1,659.59 | $3,890.45 |