- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,630.78 / $16,218.10
| Facility | | $3,467.37 | $3,630.78 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $2,570.40
| Professional | | $1,479.11 | $2,187.76 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $6,025.60 / $6,456.54
| Facility | | $2,630.27 | $6,025.60 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $5,888.44
| Professional | | $2,818.38 | $3,548.13 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $25,703.96
| Facility | | $134.90 | $11,481.54 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,691.53
| Professional | | $2,137.96 | $2,137.96 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,691.53 / $5,623.41
| Facility | | $1,288.25 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $2,818.38
| Professional | | $1,096.48 | $1,621.81 | $2,818.38 |