- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,623.41 / $13,489.63
| Facility | | $1,995.26 | $5,623.41 | $13,489.63 |
- 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
- $4,677.35 / $13,489.63 / $25,703.96
| Facility | | $4,677.35 | $13,489.63 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $5,248.07
| Professional | | $1,949.84 | $2,884.03 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,370.32 / $15,135.61
| Facility | | $323.59 | $5,370.32 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,162.28 / $6,606.93
| Professional | | $2,137.96 | $3,162.28 | $6,606.93 |
- 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
- $1,819.70 / $2,570.40 / $4,677.35
| Professional | | $1,819.70 | $2,570.40 | $4,677.35 |