- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $6,025.60 / $14,454.40
| Facility | | $1,778.28 | $6,025.60 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $2,398.83
| Professional | | $1,202.26 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $14,454.40 / $32,359.37
| Facility | | $5,754.40 | $14,454.40 | $32,359.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,862.09 / $3,467.37
| Professional | | $870.96 | $1,862.09 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $3,019.95 / $5,623.41
| Facility | | $707.95 | $3,019.95 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,365.16 / $8,511.38
| Professional | | $3,311.31 | $4,365.16 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $20,892.96 / $54,954.09
| Facility | | $5,248.07 | $20,892.96 | $54,954.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,137.96 / $3,981.07
| Professional | | $1,548.82 | $2,137.96 | $3,981.07 |