- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,897.79 / $11,220.18
| Facility | | $1,122.02 | $4,897.79 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $933.25 / $1,698.24
| Professional | | $831.76 | $933.25 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $30,199.52 / $39,810.72
| Facility | | $4,168.69 | $30,199.52 | $39,810.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,698.24
| Professional | | $812.83 | $1,047.13 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $912.01 / $1,047.13
| Facility | | $831.76 | $912.01 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $1,949.84
| Facility | | $933.25 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $9,549.93 / $16,218.10
| Facility | | $4,466.84 | $9,549.93 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $977.24 / $1,698.24
| Professional | | $741.31 | $977.24 | $1,698.24 |