- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $5,495.41 / $12,882.50
| Facility | | $1,258.93 | $5,495.41 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,023.29 / $2,630.27
| Professional | | $831.76 | $1,023.29 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $9,549.93 / $17,782.79
| Facility | | $3,235.94 | $9,549.93 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,047.13 / $1,995.26
| Professional | | $812.83 | $1,047.13 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $831.76 / $2,511.89 / $6,606.93
| Facility | | $831.76 | $2,511.89 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,202.26 / $2,570.40
| Professional | | $741.31 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $6,606.93 / $15,848.93
| Facility | | $1,778.28 | $6,606.93 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,047.13 / $1,905.46
| Professional | | $758.58 | $1,047.13 | $1,905.46 |