- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $5,248.07 / $12,589.25
| Facility | | $1,258.93 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $933.25 / $2,290.87
| Professional | | $812.83 | $933.25 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $11,220.18 / $23,988.33
| Facility | | $3,801.89 | $11,220.18 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $2,238.72
| Professional | | $812.83 | $1,202.26 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $2,511.89 / $7,762.47
| Facility | | $1,174.90 | $2,511.89 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,318.26 / $2,818.38
| Professional | | $870.96 | $1,318.26 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $16,982.44
| Facility | | $2,454.71 | $7,244.36 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,071.52 / $1,949.84
| Professional | | $758.58 | $1,071.52 | $1,949.84 |