- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,754.40 / $14,454.40
| Facility | | $1,995.26 | $5,754.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,290.87 / $4,786.30
| Professional | | $1,995.26 | $2,290.87 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $15,488.17 / $30,199.52
| Facility | | $5,248.07 | $15,488.17 | $30,199.52 |
- 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
- $398.11 / $4,466.84 / $15,488.17
| Facility | | $398.11 | $4,466.84 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,235.94 / $6,918.31
| Professional | | $2,137.96 | $3,235.94 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $11,481.54 / $28,840.32
| Facility | | $3,548.13 | $11,481.54 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,786.30
| Professional | | $1,862.09 | $2,630.27 | $4,786.30 |