- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,897.79 / $11,481.54
| Facility | | $1,862.09 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,162.28 / $6,025.60
| Professional | | $2,570.40 | $3,162.28 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $13,803.84 / $25,118.86
| Facility | | $4,570.88 | $13,803.84 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $6,918.31
| Professional | | $2,454.71 | $3,715.35 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $8,709.64 / $25,118.86
| Facility | | $323.59 | $8,709.64 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,365.16 / $9,332.54
| Professional | | $2,630.27 | $4,365.16 | $9,332.54 |
- 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
- $2,454.71 / $3,548.13 / $6,456.54
| Professional | | $2,454.71 | $3,548.13 | $6,456.54 |