- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,897.79 / $14,125.38
| Facility | | $1,380.38 | $4,897.79 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,235.94 / $5,128.61
| Professional | | $2,754.23 | $3,235.94 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $14,454.40 / $19,498.45
| Facility | | $6,456.54 | $14,454.40 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,168.69 / $6,760.83
| Professional | | $3,019.95 | $4,168.69 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,235.94 / $3,715.35
| Facility | | $2,951.21 | $3,235.94 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,073.80 / $6,760.83
| Professional | | $3,235.94 | $4,073.80 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $9,549.93 / $16,218.10
| Facility | | $1,862.09 | $9,549.93 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,467.37 / $6,165.95
| Professional | | $2,630.27 | $3,467.37 | $6,165.95 |