- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,897.79 / $11,481.54
| Facility | | $1,445.44 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,174.90 / $2,511.89
| Professional | | $1,023.29 | $1,174.90 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $8,709.64 / $16,982.44
| Facility | | $3,162.28 | $8,709.64 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,584.89 / $2,818.38
| Professional | | $1,023.29 | $1,584.89 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,884.03 / $7,943.28
| Facility | | $1,348.96 | $2,884.03 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,737.80 / $3,548.13
| Professional | | $1,122.02 | $1,737.80 | $3,548.13 |
- 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
- $954.99 / $1,380.38 / $2,511.89
| Professional | | $954.99 | $1,380.38 | $2,511.89 |