- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,435.17 / $5,224.60 / $11,923.10
| Facility | | $3,435.17 | $5,224.60 | $11,923.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.04 / $3,435.17 / $3,657.22
| Professional | | $2,769.04 | $3,435.17 | $3,657.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.59 / $7,667.10 / $12,930.89
| Facility | | $71.59 | $7,667.10 | $12,930.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,664.54 / $5,132.58 / $12,506.64
| Professional | | $2,664.54 | $5,132.58 | $12,506.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,395.99 / $14,486.72 / $29,987.53
| Facility | | $3,395.99 | $14,486.72 | $29,987.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,657.22 / $8,215.68 / $12,904.76
| Professional | | $3,657.22 | $8,215.68 | $12,904.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,403.32 / $3,134.76 / $9,168.65
| Professional | | $2,403.32 | $3,134.76 | $9,168.65 |