- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,919.64 / $2,919.60 / $6,662.82
| Facility | | $1,919.64 | $2,919.60 | $6,662.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,547.39 / $1,919.64 / $2,043.72
| Professional | | $1,547.39 | $1,919.64 | $2,043.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.97 / $4,284.51 / $7,226.01
| Facility | | $224.97 | $4,284.51 | $7,226.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,313.82 / $2,175.10 / $9,505.86
| Professional | | $1,313.82 | $2,175.10 | $9,505.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,897.74 / $8,094.98 / $16,756.59
| Facility | | $1,897.74 | $8,094.98 | $16,756.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,589.12 / $4,591.07 / $7,211.41
| Professional | | $2,589.12 | $4,591.07 | $7,211.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $3,839.86
| Professional | | $1,226.23 | $1,751.76 | $3,839.86 |