- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $13,803.84
| Facility | | $4,897.79 | $4,897.79 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,318.26 / $1,584.89
| Professional | | $354.81 | $1,318.26 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,715.35 / $11,220.18
| Facility | | $3,388.44 | $3,715.35 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.88 / $1,258.93 / $1,258.93
| Professional | | $239.88 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $257.04 / $7,079.46
| Facility | | $109.65 | $257.04 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $3,715.35
| Professional | | $1,949.84 | $1,949.84 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,174.90 / $1,949.84
| Professional | | $1,174.90 | $1,174.90 | $1,949.84 |