- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,677.35 / $11,220.18
| Facility | | $1,819.70 | $4,677.35 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $4,897.79
| Professional | | $1,995.26 | $2,398.83 | $4,897.79 |
- 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
- $1,905.46 / $3,019.95 / $5,623.41
| Professional | | $1,905.46 | $3,019.95 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $5,370.32 / $13,489.63
| Facility | | $398.11 | $5,370.32 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,311.31 / $6,760.83
| Professional | | $2,089.30 | $3,311.31 | $6,760.83 |
- 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
- $1,905.46 / $2,754.23 / $5,011.87
| Professional | | $1,905.46 | $2,754.23 | $5,011.87 |