- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $4,897.79
| Facility | | $1,380.38 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $1,318.26
| Professional | | $831.76 | $831.76 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,772.37 / $25,703.96 / $32,359.37
| Facility | | $9,772.37 | $25,703.96 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $2,344.23
| Professional | | $1,230.27 | $1,445.44 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,905.46 / $3,630.78
| Professional | | $1,023.29 | $1,905.46 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |