- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,715.35 / $3,715.35
| Facility | | $2,238.72 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $1,380.38 / $6,456.54
| Professional | | $147.91 | $1,380.38 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $676.08 / $1,698.24
| Facility | | $363.08 | $676.08 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,918.31 / $7,244.36 / $7,244.36
| Professional | | $6,918.31 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $1,737.80 / $3,388.44
| Facility | | $363.08 | $1,737.80 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,715.19 / $10,715.19 / $14,454.40
| Professional | | $10,715.19 | $10,715.19 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,570.40 / $3,715.35
| Facility | | $602.56 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $316.23
| Professional | | $316.23 | $316.23 | $316.23 |