- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,290.87 / $10,471.29
| Facility | | $2,238.72 | $2,290.87 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,380.38 / $1,621.81
| Professional | | $954.99 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,801.89 / $4,073.80
| Facility | | $1,698.24 | $3,801.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,344.23 / $3,801.89
| Professional | | $1,819.70 | $2,344.23 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $25,703.96
| Facility | | $134.90 | $11,481.54 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,659.59 / $1,778.28
| Professional | | $1,380.38 | $1,659.59 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $1,737.80 / $3,548.13
| Facility | | $812.83 | $1,737.80 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,047.13 / $1,819.70
| Professional | | $691.83 | $1,047.13 | $1,819.70 |