- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,128.61 / $11,481.54
| Facility | | $1,862.09 | $5,128.61 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,715.35 / $7,244.36
| Professional | | $2,754.23 | $3,715.35 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $15,488.17 / $30,199.52
| Facility | | $4,897.79 | $15,488.17 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,981.07 / $7,762.47
| Professional | | $2,630.27 | $3,981.07 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $9,120.11 / $25,118.86
| Facility | | $398.11 | $9,120.11 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $5,011.87 / $10,232.93
| Professional | | $2,951.21 | $5,011.87 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,890.45 / $7,585.78
| Professional | | $2,630.27 | $3,890.45 | $7,585.78 |