- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $4,466.84 / $10,964.78
| Facility | | $1,230.27 | $4,466.84 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,202.26 / $2,630.27
| Professional | | $851.14 | $1,202.26 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $7,585.78 / $16,595.87
| Facility | | $2,884.03 | $7,585.78 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $1,202.26 / $2,454.71
| Professional | | $676.08 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $3,019.95 / $7,943.28
| Facility | | $1,202.26 | $3,019.95 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,513.56 / $3,467.37
| Professional | | $851.14 | $1,513.56 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,570.88 / $10,964.78
| Facility | | $1,584.89 | $4,570.88 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $2,344.23
| Professional | | $831.76 | $1,202.26 | $2,344.23 |