- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,511.89 / $11,481.54
| Facility | | $2,454.71 | $2,511.89 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $1,778.28
| Professional | | $1,148.15 | $1,548.82 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $4,168.69 / $8,709.64
| Facility | | $2,187.76 | $4,168.69 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,570.40 / $4,073.80
| Professional | | $1,995.26 | $2,570.40 | $4,073.80 |
- 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
- $1,819.70 / $1,905.46 / $1,949.84
| Professional | | $1,819.70 | $1,905.46 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,905.46 / $3,890.45
| Facility | | $891.25 | $1,905.46 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,148.15 / $1,995.26
| Professional | | $758.58 | $1,148.15 | $1,995.26 |