- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $4,897.79 / $11,748.98
| Facility | | $1,348.96 | $4,897.79 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,023.29 / $2,570.40
| Professional | | $870.96 | $1,023.29 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $13,489.63 / $27,542.29
| Facility | | $4,570.88 | $13,489.63 | $27,542.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,258.93 / $2,398.83
| Professional | | $870.96 | $1,258.93 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $2,511.89 / $6,918.31
| Facility | | $891.25 | $2,511.89 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,412.54 / $3,019.95
| Professional | | $933.25 | $1,412.54 | $3,019.95 |
- 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
- $812.83 / $1,122.02 / $2,137.96
| Professional | | $812.83 | $1,122.02 | $2,137.96 |