- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,884.03 / $13,182.57
| Facility | | $2,818.38 | $2,884.03 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,187.76
| Professional | | $1,202.26 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $4,897.79 / $5,248.07
| Facility | | $2,137.96 | $4,897.79 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $4,786.30
| Professional | | $2,290.87 | $2,884.03 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $26,302.68
| Facility | | $134.90 | $11,481.54 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $2,187.76
| Professional | | $1,737.80 | $1,737.80 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,187.76 / $4,466.84
| Facility | | $1,023.29 | $2,187.76 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $2,290.87
| Professional | | $870.96 | $1,318.26 | $2,290.87 |