- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,094.78 / $4,023.21 / $14,313.10
| Facility | | $3,094.78 | $4,023.21 | $14,313.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,751.76 / $3,240.76 / $3,795.48
| Professional | | $1,751.76 | $3,240.76 | $3,795.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,056.24 / $5,382.87 / $7,881.17
| Facility | | $3,056.24 | $5,382.87 | $7,881.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.24 / $712.36 / $1,139.74
| Professional | | $434.24 | $712.36 | $1,139.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,919.60 / $2,919.60 / $2,919.60
| Facility | | $2,919.60 | $2,919.60 | $2,919.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,055.20 / $5,600.78 / $20,621.25
| Facility | | $3,055.20 | $5,600.78 | $20,621.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.68 / $2,966.44 / $5,664.74
| Professional | | $1,300.68 | $2,966.44 | $5,664.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.23 / $1,751.76 / $4,379.39
| Professional | | $1,226.23 | $1,751.76 | $4,379.39 |