- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,019.95 / $13,803.84
| Facility | | $2,884.03 | $3,019.95 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,819.70 / $1,949.84
| Professional | | $1,230.27 | $1,819.70 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,011.87 / $10,471.29
| Facility | | $2,630.27 | $5,011.87 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $4,897.79
| Professional | | $2,398.83 | $3,019.95 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $27,542.29
| Facility | | $134.90 | $11,481.54 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,290.87
| Professional | | $1,819.70 | $1,819.70 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,290.87 / $4,677.35
| Facility | | $1,071.52 | $2,290.87 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,380.38 / $2,398.83
| Professional | | $912.01 | $1,380.38 | $2,398.83 |