- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $7,079.46
| Facility | | $3,235.94 | $3,235.94 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $3,235.94
| Professional | | $1,737.80 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,248.07 / $8,709.64
| Facility | | $3,981.07 | $5,248.07 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $31.62 / $3,162.28
| Professional | | $21.38 | $31.62 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $18,197.01
| Facility | | $2,089.30 | $2,089.30 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,365.16 / $5,888.44 / $6,918.31
| Professional | | $4,365.16 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,905.46 / $5,623.41
| Professional | | $1,548.82 | $1,905.46 | $5,623.41 |