- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $6,918.31
| Facility | | $3,162.28 | $3,162.28 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,290.87 / $3,890.45
| Professional | | $1,737.80 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $5,248.07 / $8,511.38
| Facility | | $3,890.45 | $5,248.07 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $537.03 / $3,090.30
| Professional | | $398.11 | $537.03 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $18,197.01
| Facility | | $2,041.74 | $2,041.74 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,888.44 / $6,918.31
| Professional | | $4,265.80 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $5,495.41
| Professional | | $1,513.56 | $1,905.46 | $5,495.41 |