- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,168.69 / $10,715.19
| Facility | | $1,202.26 | $4,168.69 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,288.25 / $2,818.38
| Professional | | $794.33 | $1,288.25 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $6,165.95 / $13,803.84
| Facility | | $2,818.38 | $6,165.95 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,513.56 / $2,884.03
| Professional | | $912.01 | $1,513.56 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $3,019.95 / $10,715.19
| Facility | | $954.99 | $3,019.95 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,621.81 / $3,467.37
| Professional | | $912.01 | $1,621.81 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,623.41 / $12,302.69
| Facility | | $1,905.46 | $5,623.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,412.54 / $2,630.27
| Professional | | $831.76 | $1,412.54 | $2,630.27 |