- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $7,943.28 / $7,943.28
| Facility | | $2,238.72 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $338.84 / $4,570.88
| Professional | | $114.82 | $338.84 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,630.27 / $6,760.83
| Facility | | $1,479.11 | $2,630.27 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $4,365.16
| Professional | | $2,884.03 | $3,019.95 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $3,090.30 / $6,025.60
| Facility | | $1,258.93 | $3,090.30 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,548.82 / $3,630.78
| Professional | | $933.25 | $1,548.82 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,467.37 / $6,456.54
| Facility | | $1,995.26 | $3,467.37 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $123.03
| Professional | | $123.03 | $123.03 | $123.03 |