- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,570.88 / $11,481.54
| Facility | | $1,513.56 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $3,801.89
| Professional | | $1,380.38 | $1,621.81 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $12,022.64 / $27,542.29
| Facility | | $4,265.80 | $12,022.64 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $3,890.45
| Professional | | $1,380.38 | $2,089.30 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,365.16 / $12,589.25
| Facility | | $323.59 | $4,365.16 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,398.83 / $5,128.61
| Professional | | $1,479.11 | $2,398.83 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,995.26 / $3,715.35
| Professional | | $1,380.38 | $1,995.26 | $3,715.35 |