- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $7,762.47 / $7,762.47
| Facility | | $1,819.70 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $4,365.16
| Professional | | $1,258.93 | $1,819.70 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $10,964.78 / $18,197.01
| Facility | | $5,011.87 | $10,964.78 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $60.26 / $85.11
| Professional | | $50.12 | $60.26 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,862.09 / $7,413.10
| Facility | | $1,621.81 | $1,862.09 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $6,606.93 / $23,442.29
| Facility | | $645.65 | $6,606.93 | $23,442.29 |