- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $5,370.32 / $12,589.25
| Facility | | $1,621.81 | $5,370.32 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $3,388.44
| Professional | | $1,380.38 | $1,584.89 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $13,489.63 / $28,840.32
| Facility | | $4,677.35 | $13,489.63 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,041.74 / $3,801.89
| Professional | | $1,380.38 | $2,041.74 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $4,570.88 / $14,791.08
| Facility | | $758.58 | $4,570.88 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,344.23 / $4,786.30
| Professional | | $1,548.82 | $2,344.23 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $11,220.18 / $27,542.29
| Facility | | $3,630.78 | $11,220.18 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,905.46 / $3,388.44
| Professional | | $1,318.26 | $1,905.46 | $3,388.44 |