- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,370.32 / $16,218.10
| Facility | | $1,513.56 | $5,370.32 | $16,218.10 |
- 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
- $5,011.87 / $13,489.63 / $24,547.09
| Facility | | $5,011.87 | $13,489.63 | $24,547.09 |
- 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 / $3,162.28 / $32,359.37
| Facility | | $501.19 | $3,162.28 | $32,359.37 |
- 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
- $1,737.80 / $7,585.78 / $22,387.21
| Facility | | $1,737.80 | $7,585.78 | $22,387.21 |
- 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 |