- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,897.79 / $12,022.64
| Facility | | $1,905.46 | $4,897.79 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,019.95 / $5,495.41
| Professional | | $2,511.89 | $3,019.95 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $10,964.78 / $21,877.62
| Facility | | $3,715.35 | $10,964.78 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,019.95 / $5,754.40
| Professional | | $2,238.72 | $3,019.95 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $4,570.88 / $13,803.84
| Facility | | $371.54 | $4,570.88 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,630.78 / $7,585.78
| Professional | | $2,137.96 | $3,630.78 | $7,585.78 |
- 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
- $2,238.72 / $3,162.28 / $5,623.41
| Professional | | $2,238.72 | $3,162.28 | $5,623.41 |