- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $6,606.93 / $14,125.38
| Facility | | $3,630.78 | $6,606.93 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,659.59
| Professional | | $1,230.27 | $1,230.27 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $4,073.80 / $11,220.18
| Facility | | $363.08 | $4,073.80 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $1,288.25 / $4,897.79
| Professional | | $436.52 | $1,288.25 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $6,165.95 / $14,125.38
| Facility | | $2,884.03 | $6,165.95 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $1,318.26 / $4,168.69
| Professional | | $223.87 | $1,318.26 | $4,168.69 |