- 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
- $1,949.84 / $2,238.72 / $4,786.30
| Professional | | $1,949.84 | $2,238.72 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $10,964.78 / $21,379.62
| Facility | | $3,715.35 | $10,964.78 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $5,370.32
| Professional | | $1,949.84 | $2,884.03 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,623.41 / $15,488.17
| Facility | | $323.59 | $5,623.41 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,235.94 / $6,606.93
| Professional | | $2,137.96 | $3,235.94 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $7,244.36 / $16,595.87
| Facility | | $2,344.23 | $7,244.36 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $4,786.30
| Professional | | $1,819.70 | $2,630.27 | $4,786.30 |