- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $4,677.35
| Facility | | $2,137.96 | $2,137.96 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $2,041.74
| Professional | | $1,122.02 | $1,584.89 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,548.13 / $5,754.40
| Facility | | $2,630.27 | $3,548.13 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.18 / $1,380.38 / $4,265.80
| Professional | | $13.18 | $1,380.38 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,467.37 / $12,302.69
| Facility | | $1,380.38 | $3,467.37 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,890.45 / $4,570.88
| Professional | | $2,884.03 | $3,890.45 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $3,715.35
| Professional | | $1,023.29 | $1,288.25 | $3,715.35 |