- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,248.07 / $11,481.54
| Facility | | $1,862.09 | $5,248.07 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,801.89 / $7,079.46
| Professional | | $3,162.28 | $3,801.89 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $9,549.93 / $17,782.79
| Facility | | $3,548.13 | $9,549.93 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,265.80 / $7,413.10
| Professional | | $3,311.31 | $4,265.80 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $12,022.64 / $28,840.32
| Facility | | $8,511.38 | $12,022.64 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $9,772.37 / $14,791.08
| Professional | | $5,495.41 | $9,772.37 | $14,791.08 |
- 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
- $2,884.03 / $4,073.80 / $7,413.10
| Professional | | $2,884.03 | $4,073.80 | $7,413.10 |