- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,897.79 / $11,748.98
| Facility | | $1,202.26 | $4,897.79 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $724.44 / $870.96 / $1,905.46
| Professional | | $724.44 | $870.96 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $10,232.93 / $22,387.21
| Facility | | $3,548.13 | $10,232.93 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,047.13 / $1,995.26
| Professional | | $691.83 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $2,290.87 / $7,244.36
| Facility | | $1,047.13 | $2,290.87 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $2,630.27
| Professional | | $794.33 | $1,202.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $5,754.40 / $14,125.38
| Facility | | $1,949.84 | $5,754.40 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $933.25 / $1,737.80
| Professional | | $660.69 | $933.25 | $1,737.80 |