- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,897.79 / $11,481.54
| Facility | | $1,513.56 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,348.96 / $2,818.38
| Professional | | $1,148.15 | $1,348.96 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,709.64 / $23,442.29
| Facility | | $3,311.31 | $8,709.64 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,513.56 / $3,090.30
| Professional | | $912.01 | $1,513.56 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,890.45 / $11,220.18
| Facility | | $2,187.76 | $3,890.45 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,862.09 / $3,981.07
| Professional | | $1,230.27 | $1,862.09 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $9,120.11 / $20,892.96
| Facility | | $3,019.95 | $9,120.11 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,754.23
| Professional | | $1,047.13 | $1,479.11 | $2,754.23 |