- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,344.23 / $10,471.29
| Facility | | $2,238.72 | $2,344.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,412.54 / $1,737.80
| Professional | | $1,047.13 | $1,412.54 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,890.45 / $3,890.45
| Facility | | $1,698.24 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,801.89
| Professional | | $1,862.09 | $2,290.87 | $3,801.89 |
- 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
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,737.80 / $3,630.78
| Facility | | $1,047.13 | $1,737.80 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $1,862.09
| Professional | | $707.95 | $1,047.13 | $1,862.09 |