- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,011.87 / $13,182.57
| Facility | | $1,513.56 | $5,011.87 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,479.11 / $3,630.78
| Professional | | $1,202.26 | $1,479.11 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,232.93 / $20,417.38
| Facility | | $3,630.78 | $10,232.93 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $3,630.78
| Professional | | $1,202.26 | $1,778.28 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $3,467.37 / $9,772.37
| Facility | | $323.59 | $3,467.37 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,949.84 / $4,168.69
| Professional | | $1,258.93 | $1,949.84 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $7,079.46 / $16,218.10
| Facility | | $2,398.83 | $7,079.46 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,548.82 / $2,884.03
| Professional | | $1,122.02 | $1,548.82 | $2,884.03 |