- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,344.23 / $4,897.79
| Facility | | $1,202.26 | $2,344.23 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,318.26 / $1,949.84
| Professional | | $1,122.02 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $17,378.01 / $25,703.96
| Facility | | $8,317.64 | $17,378.01 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,412.54 / $2,238.72
| Professional | | $1,023.29 | $1,412.54 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $1,230.27
| Facility | | $1,047.13 | $1,148.15 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,659.59 / $3,235.94
| Professional | | $1,122.02 | $1,659.59 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,754.40 / $12,022.64
| Facility | | $1,412.54 | $5,754.40 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,344.23
| Professional | | $1,047.13 | $1,479.11 | $2,344.23 |