- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,677.35 / $20,892.96
| Facility | | $4,466.84 | $4,677.35 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,884.03 / $3,467.37
| Professional | | $2,290.87 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $7,762.47 / $16,218.10
| Facility | | $3,981.07 | $7,762.47 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,677.35 / $7,585.78
| Professional | | $3,715.35 | $4,677.35 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $10,471.29 / $26,302.68
| Facility | | $151.36 | $10,471.29 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,467.37 / $3,548.13
| Professional | | $3,388.44 | $3,467.37 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,467.37 / $7,244.36
| Facility | | $1,659.59 | $3,467.37 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $3,715.35
| Professional | | $1,412.54 | $2,089.30 | $3,715.35 |