- 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
- $3,019.95 / $3,801.89 / $6,760.83
| Professional | | $3,019.95 | $3,801.89 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $14,454.40 / $28,840.32
| Facility | | $4,466.84 | $14,454.40 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,466.84 / $8,912.51
| Professional | | $2,951.21 | $4,466.84 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $9,332.54 / $25,703.96
| Facility | | $323.59 | $9,332.54 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $5,248.07 / $10,471.29
| Professional | | $3,235.94 | $5,248.07 | $10,471.29 |
- 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
- $3,019.95 / $4,365.16 / $7,943.28
| Professional | | $3,019.95 | $4,365.16 | $7,943.28 |