- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,466.84 / $10,232.93
| Facility | | $2,238.72 | $4,466.84 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $5,011.87
| Professional | | $3,162.28 | $3,162.28 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $6,025.60 / $7,762.47
| Facility | | $4,466.84 | $6,025.60 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $5,128.61
| Professional | | $1,819.70 | $3,019.95 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $36.31 / $40.74
| Professional | | $31.62 | $36.31 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.92 / $26.92 / $26.92
| Professional | | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,905.46 / $6,606.93
| Facility | | $776.25 | $1,905.46 | $6,606.93 |