- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,981.07 / $7,079.46
| Facility | | $2,398.83 | $3,981.07 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,344.23 / $2,818.38
| Professional | | $1,584.89 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $851.14 / $851.14
| Professional | | $724.44 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $42,657.95 / $77,624.71
| Facility | | $3,467.37 | $42,657.95 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,073.80 / $53,703.18
| Professional | | $3,235.94 | $4,073.80 | $53,703.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,677.35 / $4,677.35
| Facility | | $1,905.46 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,125.38 / $14,125.38 / $14,125.38
| Professional | | $14,125.38 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,884.03
| Professional | | $1,230.27 | $1,737.80 | $2,884.03 |