- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $3,715.35 / $9,772.37
| Facility | | $1,122.02 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,071.52 / $2,344.23
| Professional | | $870.96 | $1,071.52 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $6,165.95 / $14,125.38
| Facility | | $2,344.23 | $6,165.95 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,258.93 / $2,398.83
| Professional | | $812.83 | $1,258.93 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,884.03 / $6,606.93
| Facility | | $1,584.89 | $2,884.03 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,445.44 / $3,090.30
| Professional | | $891.25 | $1,445.44 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $5,754.40 / $13,489.63
| Facility | | $1,995.26 | $5,754.40 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,137.96
| Professional | | $812.83 | $1,174.90 | $2,137.96 |