- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,570.88 / $11,481.54
| Facility | | $1,412.54 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,445.44 / $3,162.28
| Professional | | $1,174.90 | $1,445.44 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,302.69 / $26,915.35
| Facility | | $4,677.35 | $12,302.69 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $3,388.44
| Professional | | $1,202.26 | $1,905.46 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $2,951.21 / $11,220.18
| Facility | | $630.96 | $2,951.21 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,949.84 / $4,265.80
| Professional | | $1,288.25 | $1,949.84 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,232.93 / $23,988.33
| Facility | | $3,630.78 | $10,232.93 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $3,019.95
| Professional | | $1,096.48 | $1,584.89 | $3,019.95 |