- 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
- $3,162.28 / $3,981.07 / $7,244.36
| Professional | | $3,162.28 | $3,981.07 | $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
- $2,951.21 / $4,570.88 / $9,120.11
| Professional | | $2,951.21 | $4,570.88 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $9,772.37 / $26,915.35
| Facility | | $323.59 | $9,772.37 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $5,495.41 / $11,220.18
| Professional | | $3,467.37 | $5,495.41 | $11,220.18 |
- 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
- $3,162.28 / $4,677.35 / $8,317.64
| Professional | | $3,162.28 | $4,677.35 | $8,317.64 |