- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $5,248.07 / $12,302.69
| Facility | | $1,258.93 | $5,248.07 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $933.25 / $2,187.76
| Professional | | $794.33 | $933.25 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $8,912.51 / $16,982.44
| Facility | | $3,388.44 | $8,912.51 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,288.25 / $2,238.72
| Professional | | $812.83 | $1,288.25 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $2,398.83 / $6,309.57
| Facility | | $323.59 | $2,398.83 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,380.38 / $2,754.23
| Professional | | $891.25 | $1,380.38 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $7,413.10 / $16,982.44
| Facility | | $2,344.23 | $7,413.10 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $1,949.84
| Professional | | $758.58 | $1,096.48 | $1,949.84 |