- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $5,370.32
| Facility | | $2,454.71 | $2,454.71 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,819.70 / $2,344.23
| Professional | | $1,318.26 | $1,819.70 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,073.80 / $6,606.93
| Facility | | $3,019.95 | $4,073.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $269.15 / $1,584.89
| Professional | | $199.53 | $269.15 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $14,125.38
| Facility | | $1,584.89 | $1,584.89 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,466.84 / $5,248.07
| Professional | | $2,511.89 | $4,466.84 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $4,265.80
| Professional | | $1,174.90 | $1,445.44 | $4,265.80 |