- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,897.79 / $10,471.29
| Facility | | $1,778.28 | $4,897.79 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,096.48 / $2,187.76
| Professional | | $891.25 | $1,096.48 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,778.28 / $2,290.87
| Professional | | $912.01 | $1,778.28 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $2,511.89
| Professional | | $1,096.48 | $1,548.82 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,698.24
| Professional | | $1,548.82 | $1,548.82 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $6,165.95 / $15,135.61
| Facility | | $3,311.31 | $6,165.95 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $2,818.38
| Professional | | $891.25 | $1,258.93 | $2,818.38 |