- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $5,248.07 / $12,589.25
| Facility | | $1,412.54 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $2,290.87
| Professional | | $891.25 | $1,023.29 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $10,715.19 / $22,908.68
| Facility | | $3,630.78 | $10,715.19 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,318.26 / $2,454.71
| Professional | | $891.25 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,090.30 / $13,182.57
| Facility | | $1,412.54 | $3,090.30 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,479.11 / $3,090.30
| Professional | | $977.24 | $1,479.11 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $9,120.11 / $20,892.96
| Facility | | $3,019.95 | $9,120.11 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,174.90 / $2,187.76
| Professional | | $831.76 | $1,174.90 | $2,187.76 |