- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,168.69 / $19,054.61
| Facility | | $4,073.80 | $4,168.69 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,570.40 / $2,951.21
| Professional | | $1,737.80 | $2,570.40 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $6,918.31 / $6,918.31
| Facility | | $3,090.30 | $6,918.31 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,168.69 / $6,918.31
| Professional | | $3,311.31 | $4,168.69 | $6,918.31 |
- 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
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $3,162.28 / $6,456.54
| Facility | | $1,479.11 | $3,162.28 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,905.46 / $3,311.31
| Professional | | $1,258.93 | $1,905.46 | $3,311.31 |