- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,128.61 / $12,022.64
| Facility | | $1,905.46 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,162.28 / $6,456.54
| Professional | | $2,630.27 | $3,162.28 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $12,589.25 / $29,512.09
| Facility | | $3,467.37 | $12,589.25 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,548.13 / $6,918.31
| Professional | | $2,398.83 | $3,548.13 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $8,709.64 / $23,988.33
| Facility | | $3,162.28 | $8,709.64 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,370.32 / $8,128.31 / $12,022.64
| Professional | | $5,370.32 | $8,128.31 | $12,022.64 |
- 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
- $2,398.83 / $3,467.37 / $6,606.93
| Professional | | $2,398.83 | $3,467.37 | $6,606.93 |