- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,248.07 / $12,589.25
| Facility | | $1,318.26 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,047.13 / $2,344.23
| Professional | | $912.01 | $1,047.13 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $11,481.54 / $28,840.32
| Facility | | $3,890.45 | $11,481.54 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,318.26 / $2,511.89
| Professional | | $912.01 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $2,511.89 / $12,022.64
| Facility | | $1,202.26 | $2,511.89 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $3,162.28
| Professional | | $977.24 | $1,479.11 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $11,748.98 / $28,840.32
| Facility | | $3,715.35 | $11,748.98 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $2,187.76
| Professional | | $831.76 | $1,174.90 | $2,187.76 |