- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,897.79 / $11,481.54
| Facility | | $1,819.70 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $6,456.54
| Professional | | $2,570.40 | $3,162.28 | $6,456.54 |
- 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
- $2,454.71 / $3,715.35 / $7,244.36
| Professional | | $2,454.71 | $3,715.35 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $6,760.83 / $17,782.79
| Facility | | $398.11 | $6,760.83 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $4,365.16 / $8,912.51
| Professional | | $2,691.53 | $4,365.16 | $8,912.51 |
- 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
- $2,454.71 / $3,548.13 / $6,606.93
| Professional | | $2,454.71 | $3,548.13 | $6,606.93 |