- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,786.30 / $11,481.54
| Facility | | $1,202.26 | $4,786.30 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $851.14 / $1,995.26
| Professional | | $741.31 | $851.14 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $10,471.29 / $22,387.21
| Facility | | $3,548.13 | $10,471.29 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,071.52 / $2,041.74
| Professional | | $741.31 | $1,071.52 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,454.71 / $6,760.83
| Facility | | $1,412.54 | $2,454.71 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $2,570.40
| Professional | | $812.83 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $16,982.44
| Facility | | $2,454.71 | $7,244.36 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $977.24 / $1,778.28
| Professional | | $691.83 | $977.24 | $1,778.28 |