- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,890.45 / $7,943.28
| Facility | | $2,041.74 | $3,890.45 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $1,148.15 / $2,344.23
| Professional | | $371.54 | $1,148.15 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,981.07 / $5,888.44
| Facility | | $1,230.27 | $3,981.07 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,128.61 / $15,488.17
| Professional | | $4,897.79 | $5,128.61 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,137.96 / $5,128.61
| Facility | | $1,288.25 | $2,137.96 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,288.25 / $2,570.40
| Professional | | $1,023.29 | $1,288.25 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,290.87 / $5,495.41
| Facility | | $1,348.96 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,202.26 / $1,949.84
| Professional | | $1,023.29 | $1,202.26 | $1,949.84 |