- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,128.61 / $11,748.98
| Facility | | $1,380.38 | $5,128.61 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $812.83 / $1,148.15
| Professional | | $676.08 | $812.83 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $11,481.54 / $28,840.32
| Facility | | $3,548.13 | $11,481.54 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $602.56 / $1,174.90
| Professional | | $309.03 | $602.56 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,691.53 / $11,220.18
| Facility | | $1,174.90 | $2,691.53 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,380.38 / $3,162.28
| Professional | | $562.34 | $1,380.38 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $11,481.54 / $27,542.29
| Facility | | $3,630.78 | $11,481.54 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $977.24 / $1,737.80
| Professional | | $676.08 | $977.24 | $1,737.80 |