- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $4,786.30 / $11,481.54
| Facility | | $1,148.15 | $4,786.30 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $870.96 / $1,949.84
| Professional | | $660.69 | $870.96 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $8,317.64 / $15,488.17
| Facility | | $3,090.30 | $8,317.64 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,023.29 / $1,949.84
| Professional | | $676.08 | $1,023.29 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $2,238.72 / $6,309.57
| Facility | | $977.24 | $2,238.72 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $2,630.27
| Professional | | $758.58 | $1,174.90 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,495.41 / $12,302.69
| Facility | | $1,949.84 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $933.25 / $1,778.28
| Professional | | $645.65 | $933.25 | $1,778.28 |