- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $4,265.80 / $19,054.61
| Facility | | $4,073.80 | $4,265.80 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,570.40 / $3,019.95
| Professional | | $1,737.80 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $7,079.46 / $7,079.46
| Facility | | $3,162.28 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,168.69 / $6,918.31
| Professional | | $3,388.44 | $4,168.69 | $6,918.31 |
- 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
- $2,238.72 / $2,238.72 / $2,238.72
| Professional | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,235.94 / $6,606.93
| Facility | | $1,513.56 | $3,235.94 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $3,388.44
| Professional | | $1,288.25 | $1,905.46 | $3,388.44 |