- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,495.41 / $20,892.96
| Facility | | $4,466.84 | $5,495.41 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,019.95 / $5,495.41
| Professional | | $2,454.71 | $3,019.95 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $7,762.47 / $16,218.10
| Facility | | $3,467.37 | $7,762.47 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,073.80 / $5,370.32
| Professional | | $1,862.09 | $4,073.80 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,659.59 / $2,089.30
| Professional | | $1,412.54 | $1,659.59 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $11,481.54 / $28,183.83
| Facility | | $134.90 | $11,481.54 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,290.87 / $2,818.38
| Professional | | $2,089.30 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $3,548.13 / $7,244.36
| Facility | | $1,659.59 | $3,548.13 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,089.30 / $3,630.78
| Professional | | $1,412.54 | $2,089.30 | $3,630.78 |