- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,495.41 / $12,589.25
| Facility | | $1,380.38 | $5,495.41 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $1,380.38
| Professional | | $758.58 | $1,071.52 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $7,244.36 / $21,379.62
| Facility | | $3,630.78 | $7,244.36 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,819.70 / $3,548.13
| Professional | | $1,096.48 | $1,819.70 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,862.09 / $5,495.41
| Facility | | $891.25 | $1,862.09 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $870.96 / $2,818.38
| Professional | | $691.83 | $870.96 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $8,912.51 / $20,892.96
| Facility | | $2,884.03 | $8,912.51 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,318.26 / $2,398.83
| Professional | | $812.83 | $1,318.26 | $2,398.83 |