- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $6,918.31 / $11,748.98
| Facility | | $4,365.16 | $6,918.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $891.25 / $1,737.80
| Professional | | $758.58 | $891.25 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Facility | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $1,096.48 / $2,089.30
| Professional | | $691.83 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $1,621.81
| Professional | | $870.96 | $1,071.52 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $977.24 / $1,949.84
| Professional | | $660.69 | $977.24 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $5,248.07 / $10,471.29
| Facility | | $1,513.56 | $5,248.07 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $870.96 / $1,737.80
| Professional | | $588.84 | $870.96 | $1,737.80 |