- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,677.35 / $12,589.25
| Facility | | $1,819.70 | $4,677.35 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,398.83 / $4,365.16
| Professional | | $1,995.26 | $2,398.83 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,715.19 / $21,877.62
| Facility | | $3,630.78 | $10,715.19 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $4,677.35
| Professional | | $1,862.09 | $2,454.71 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $3,630.78 / $11,220.18
| Facility | | $323.59 | $3,630.78 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,884.03 / $6,025.60
| Professional | | $1,698.24 | $2,884.03 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,818.38 / $9,772.37
| Facility | | $537.03 | $2,818.38 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,511.89 / $4,466.84
| Professional | | $1,778.28 | $2,511.89 | $4,466.84 |