- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,461.54 / $5,490.36 / $11,401.45
| Facility | | $3,461.54 | $5,490.36 | $11,401.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,928.20 / $3,430.17 / $3,764.82
| Professional | | $2,928.20 | $3,430.17 | $3,764.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.80 / $6,138.74 / $16,314.21
| Facility | | $436.80 | $6,138.74 | $16,314.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.00 / $208.00 / $3,919.76
| Professional | | $208.00 | $208.00 | $3,919.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,487.15 / $5,663.74 / $12,395.52
| Facility | | $3,487.15 | $5,663.74 | $12,395.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,095.32 / $5,095.32 / $6,104.77
| Professional | | $5,095.32 | $5,095.32 | $6,104.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,764.82 / $3,764.82 / $5,019.76
| Facility | | $3,764.82 | $3,764.82 | $5,019.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,756.91 / $2,509.88 / $4,731.12
| Professional | | $1,756.91 | $2,509.88 | $4,731.12 |