- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,677.35 / $13,182.57
| Facility | | $4,677.35 | $4,677.35 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,380.38 / $1,621.81
| Professional | | $1,023.29 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,548.13 / $10,715.19
| Facility | | $3,235.94 | $3,548.13 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $1,202.26 / $1,737.80
| Professional | | $208.93 | $1,202.26 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,265.80 / $6,760.83
| Facility | | $1,202.26 | $4,265.80 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $3,548.13
| Professional | | $1,862.09 | $1,862.09 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,122.02 / $1,862.09
| Professional | | $1,122.02 | $1,122.02 | $1,862.09 |