- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,466.84 / $10,964.78
| Facility | | $1,096.48 | $4,466.84 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $812.83 / $1,819.70
| Professional | | $707.95 | $812.83 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $10,471.29 / $22,387.21
| Facility | | $3,801.89 | $10,471.29 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $977.24 / $1,905.46
| Professional | | $707.95 | $977.24 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $2,041.74 / $6,760.83
| Facility | | $707.95 | $2,041.74 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,148.15 / $2,454.71
| Professional | | $741.31 | $1,148.15 | $2,454.71 |
- 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
- $660.69 / $933.25 / $1,737.80
| Professional | | $660.69 | $933.25 | $1,737.80 |