- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,365.16 / $10,964.78
| Facility | | $1,122.02 | $4,365.16 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $812.83 / $1,949.84
| Professional | | $691.83 | $812.83 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $8,511.38 / $20,417.38
| Facility | | $3,162.28 | $8,511.38 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,096.48 / $1,949.84
| Professional | | $691.83 | $1,096.48 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.24 / $1,995.26 / $5,623.41
| Facility | | $977.24 | $1,995.26 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,202.26 / $2,398.83
| Professional | | $776.25 | $1,202.26 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,888.44 / $14,125.38
| Facility | | $1,949.84 | $5,888.44 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $954.99 / $1,737.80
| Professional | | $645.65 | $954.99 | $1,737.80 |