- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,011.87 / $11,748.98
| Facility | | $1,905.46 | $5,011.87 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $7,413.10
| Professional | | $2,398.83 | $3,019.95 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,302.69 / $24,547.09
| Facility | | $4,677.35 | $12,302.69 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,548.13 / $6,760.83
| Professional | | $2,398.83 | $3,548.13 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $7,079.46 / $18,197.01
| Facility | | $398.11 | $7,079.46 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,981.07 / $8,511.38
| Professional | | $2,630.27 | $3,981.07 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,232.93 / $23,988.33
| Facility | | $3,630.78 | $10,232.93 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,235.94 / $6,025.60
| Professional | | $2,290.87 | $3,235.94 | $6,025.60 |