- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $14,125.38
| Facility | | $5,128.61 | $5,128.61 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $1,778.28
| Professional | | $1,096.48 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,890.45 / $11,748.98
| Facility | | $3,467.37 | $3,890.45 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $1,318.26 / $1,905.46
| Professional | | $302.00 | $1,318.26 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,309.57 / $8,912.51
| Facility | | $3,311.31 | $6,309.57 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $3,890.45
| Professional | | $2,041.74 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $2,137.96
| Professional | | $1,230.27 | $1,230.27 | $2,137.96 |