- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,897.79 / $12,022.64
| Facility | | $1,819.70 | $4,897.79 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,630.27 / $4,897.79
| Professional | | $2,089.30 | $2,630.27 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $12,882.50 / $28,840.32
| Facility | | $4,570.88 | $12,882.50 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,235.94 / $6,309.57
| Professional | | $2,137.96 | $3,235.94 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $6,165.95 / $17,782.79
| Facility | | $398.11 | $6,165.95 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,981.07 / $7,585.78
| Professional | | $2,344.23 | $3,981.07 | $7,585.78 |
- 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 / $3,715.35 / $6,456.54
| Professional | | $2,187.76 | $3,715.35 | $6,456.54 |