- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $6,918.31
| Facility | | $3,162.28 | $3,162.28 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,187.76 / $3,090.30
| Professional | | $1,659.59 | $2,187.76 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,897.79 / $8,511.38
| Facility | | $2,454.71 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,090.30 / $4,168.69
| Professional | | $1,412.54 | $3,090.30 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $5,128.61 / $18,197.01
| Facility | | $2,041.74 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,888.44 / $6,918.31
| Professional | | $4,265.80 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,905.46 / $5,495.41
| Professional | | $1,513.56 | $1,905.46 | $5,495.41 |