- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,757.75 / $2,917.79 / $6,055.67
| Facility | | $1,757.75 | $2,917.79 | $6,055.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.16 / $1,672.01 / $2,079.29
| Professional | | $1,286.16 | $1,672.01 | $2,079.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,074.36 / $2,368.67 / $7,416.86
| Facility | | $2,074.36 | $2,368.67 | $7,416.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $857.44 / $857.44 / $1,919.63
| Professional | | $857.44 | $857.44 | $1,919.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,408.90 / $3,250.66 / $5,797.89
| Facility | | $1,408.90 | $3,250.66 | $5,797.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.10 / $2,463.13 / $3,547.65
| Professional | | $1,136.10 | $2,463.13 | $3,547.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,929.24 / $1,929.24 / $1,929.24
| Facility | | $1,929.24 | $1,929.24 | $1,929.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.05 / $900.31 / $2,143.60
| Professional | | $301.05 | $900.31 | $2,143.60 |