- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,011.87 / $11,481.54
| Facility | | $1,949.84 | $5,011.87 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,570.40 / $5,754.40
| Professional | | $2,238.72 | $2,570.40 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $11,220.18 / $22,908.68
| Facility | | $3,715.35 | $11,220.18 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $6,025.60
| Professional | | $2,187.76 | $3,388.44 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $5,011.87 / $17,378.01
| Facility | | $398.11 | $5,011.87 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,715.35 / $7,585.78
| Professional | | $2,398.83 | $3,715.35 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $7,244.36 / $16,982.44
| Facility | | $2,041.74 | $7,244.36 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,951.21 / $5,370.32
| Professional | | $2,041.74 | $2,951.21 | $5,370.32 |