- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,248.07 / $15,488.17
| Facility | | $1,513.56 | $5,248.07 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,380.38 / $2,570.40
| Professional | | $1,148.15 | $1,380.38 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,302.69 / $22,387.21
| Facility | | $4,677.35 | $12,302.69 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,445.44 / $2,754.23
| Professional | | $1,096.48 | $1,445.44 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $2,187.76 / $28,183.83
| Facility | | $501.19 | $2,187.76 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,698.24 / $3,548.13
| Professional | | $1,096.48 | $1,698.24 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $5,495.41 / $20,892.96
| Facility | | $1,348.96 | $5,495.41 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $2,630.27
| Professional | | $1,071.52 | $1,445.44 | $2,630.27 |