- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $6,025.60 / $14,791.08
| Facility | | $1,348.96 | $6,025.60 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,071.52 / $2,570.40
| Professional | | $812.83 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $10,471.29 / $20,892.96
| Facility | | $3,715.35 | $10,471.29 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,230.27 / $2,290.87
| Professional | | $870.96 | $1,230.27 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $2,754.23 / $7,762.47
| Facility | | $323.59 | $2,754.23 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,412.54 / $2,951.21
| Professional | | $870.96 | $1,412.54 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,128.61 / $12,022.64
| Facility | | $1,905.46 | $5,128.61 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,148.15 / $2,089.30
| Professional | | $812.83 | $1,148.15 | $2,089.30 |