- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,370.32 / $14,791.08
| Facility | | $5,370.32 | $5,370.32 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,479.11 / $1,862.09
| Professional | | $1,148.15 | $1,479.11 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,073.80 / $12,302.69
| Facility | | $3,630.78 | $4,073.80 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13.18 / $1,380.38 / $1,995.26
| Professional | | $13.18 | $1,380.38 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $6,606.93 / $9,332.54
| Facility | | $3,467.37 | $6,606.93 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $4,073.80
| Professional | | $2,137.96 | $2,137.96 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $2,137.96
| Professional | | $1,288.25 | $1,288.25 | $2,137.96 |