- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,786.30 / $11,481.54
| Facility | | $1,819.70 | $4,786.30 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $6,165.95
| Professional | | $2,187.76 | $2,818.38 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $14,454.40 / $28,840.32
| Facility | | $4,265.80 | $14,454.40 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $6,309.57
| Professional | | $2,187.76 | $3,388.44 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $6,760.83 / $18,620.87
| Facility | | $323.59 | $6,760.83 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,801.89 / $7,762.47
| Professional | | $2,398.83 | $3,801.89 | $7,762.47 |
- 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
- $2,187.76 / $3,162.28 / $5,754.40
| Professional | | $2,187.76 | $3,162.28 | $5,754.40 |