- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,548.13 / $9,772.37
| Facility | | $1,148.15 | $3,548.13 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,388.44 / $4,265.80
| Professional | | $2,187.76 | $3,388.44 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $7,943.28 / $15,135.61
| Facility | | $2,754.23 | $7,943.28 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.05 / $3,235.94 / $6,456.54
| Professional | | $389.05 | $3,235.94 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $724.44 / $4,677.35 / $4,677.35
| Facility | | $724.44 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $13,182.57 / $13,182.57
| Professional | | $5,495.41 | $13,182.57 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $2,884.03 / $6,309.57
| Facility | | $1,023.29 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,570.88 / $7,762.47
| Professional | | $3,090.30 | $4,570.88 | $7,762.47 |