- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,388.44 / $15,488.17
| Facility | | $3,311.31 | $3,388.44 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $2,570.40
| Professional | | $1,412.54 | $2,089.30 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $5,623.41 / $6,025.60
| Facility | | $2,511.89 | $5,623.41 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,388.44 / $5,623.41
| Professional | | $2,691.53 | $3,388.44 | $5,623.41 |
- 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
- $2,041.74 / $2,041.74 / $2,570.40
| Professional | | $2,041.74 | $2,041.74 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,570.40 / $5,248.07
| Facility | | $1,202.26 | $2,570.40 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,548.82 / $2,691.53
| Professional | | $1,023.29 | $1,548.82 | $2,691.53 |