- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,754.40 / $13,489.63
| Facility | | $1,862.09 | $5,754.40 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,187.76 / $2,754.23
| Professional | | $1,445.44 | $2,187.76 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $13,489.63 / $26,302.68
| Facility | | $5,248.07 | $13,489.63 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $4,677.35
| Professional | | $1,905.46 | $2,238.72 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,890.45 / $3,890.45
| Facility | | $398.11 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,964.78 / $10,964.78
| Professional | | $3,630.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,311.31 / $12,589.25
| Facility | | $851.14 | $3,311.31 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $5,011.87
| Professional | | $1,949.84 | $2,818.38 | $5,011.87 |