- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $4,897.79 / $21,877.62
| Facility | | $4,677.35 | $4,897.79 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,951.21 / $3,715.35
| Professional | | $1,995.26 | $2,951.21 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $8,128.31 / $8,709.64
| Facility | | $3,630.78 | $8,128.31 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,786.30 / $7,943.28
| Professional | | $3,890.45 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $29,512.09
| Facility | | $134.90 | $11,481.54 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,715.35
| Professional | | $2,884.03 | $2,884.03 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,715.35 / $7,585.78
| Facility | | $1,737.80 | $3,715.35 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,187.76 / $3,890.45
| Professional | | $1,479.11 | $2,187.76 | $3,890.45 |