- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,265.80 / $8,912.51
| Facility | | $3,019.95 | $4,265.80 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $2,630.27
| Professional | | $1,513.56 | $1,513.56 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,011.87 / $8,128.31
| Facility | | $3,715.35 | $5,011.87 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,096.48 / $3,890.45
| Professional | | $794.33 | $1,096.48 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,019.95 / $12,022.64
| Facility | | $1,949.84 | $3,019.95 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,495.41 / $6,456.54
| Professional | | $4,073.80 | $5,495.41 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,819.70 / $5,248.07
| Professional | | $1,445.44 | $1,819.70 | $5,248.07 |