- 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
- $2,238.72 / $2,630.27 / $5,495.41
| Professional | | $2,238.72 | $2,630.27 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $13,803.84 / $26,302.68
| Facility | | $5,011.87 | $13,803.84 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,311.31 / $6,165.95
| Professional | | $2,187.76 | $3,311.31 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,897.79 / $17,378.01
| Facility | | $398.11 | $4,897.79 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $7,943.28
| Professional | | $2,454.71 | $3,715.35 | $7,943.28 |
- 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
- $2,089.30 / $3,019.95 / $5,495.41
| Professional | | $2,089.30 | $3,019.95 | $5,495.41 |