- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,679.70 / $1,743.48 / $9,457.34
| Facility | | $1,679.70 | $1,743.48 | $9,457.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,488.34 / $1,700.96 / $2,126.19
| Professional | | $1,488.34 | $1,700.96 | $2,126.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.28 / $13.28 / $13.28
| Facility | | $13.28 | $13.28 | $13.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.28 / $13.28 / $13.28
| Professional | | $11.28 | $13.28 | $13.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,551.44 / $27,906.38 / $53,580.24
| Facility | | $2,551.44 | $27,906.38 | $53,580.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,445.13 / $2,976.68 / $39,436.71
| Professional | | $2,445.13 | $2,976.68 | $39,436.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,382.03 / $1,654.40 / $2,805.52
| Facility | | $1,382.03 | $1,654.40 | $2,805.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,467.73 / $10,248.28 / $10,248.28
| Professional | | $2,467.73 | $10,248.28 | $10,248.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $920.64 / $1,275.72 / $2,338.82
| Professional | | $920.64 | $1,275.72 | $2,338.82 |