- 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
- $2,398.83 / $2,884.03 / $6,606.93
| Professional | | $2,398.83 | $2,884.03 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $15,488.17 / $29,512.09
| Facility | | $4,897.79 | $15,488.17 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,467.37 / $6,606.93
| Professional | | $2,290.87 | $3,467.37 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $7,943.28 / $22,908.68
| Facility | | $323.59 | $7,943.28 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,168.69 / $9,120.11
| Professional | | $2,511.89 | $4,168.69 | $9,120.11 |
- 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
- $2,290.87 / $3,311.31 / $6,456.54
| Professional | | $2,290.87 | $3,311.31 | $6,456.54 |