- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $5,248.07 / $12,589.25
| Facility | | $1,318.26 | $5,248.07 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,148.15 / $3,090.30
| Professional | | $933.25 | $1,148.15 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $8,317.64 / $15,488.17
| Facility | | $3,162.28 | $8,317.64 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $2,570.40
| Professional | | $933.25 | $1,348.96 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,570.40 / $7,244.36
| Facility | | $398.11 | $2,570.40 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,548.82 / $3,388.44
| Professional | | $977.24 | $1,548.82 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,623.41 / $12,302.69
| Facility | | $1,905.46 | $5,623.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,258.93 / $2,344.23
| Professional | | $891.25 | $1,258.93 | $2,344.23 |