- 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
- $1,778.28 / $2,754.23 / $3,467.37
| Professional | | $1,778.28 | $2,754.23 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,762.47 / $8,317.64
| Facility | | $3,388.44 | $7,762.47 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,570.88 / $7,585.78
| Professional | | $3,715.35 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $28,183.83
| Facility | | $134.90 | $11,481.54 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,467.37
| Professional | | $2,754.23 | $2,754.23 | $3,467.37 |
- 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 |