- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,365.16 / $7,079.46 / $14,125.38
| Facility | | $4,365.16 | $7,079.46 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $891.25 / $1,819.70
| Professional | | $691.83 | $891.25 | $1,819.70 |
- 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
- $724.44 / $1,513.56 / $1,949.84
| Professional | | $724.44 | $1,513.56 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $1,949.84
| Professional | | $933.25 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,445.44
| Professional | | $1,412.54 | $1,412.54 | $1,445.44 |
- 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
- $831.76 / $1,096.48 / $2,089.30
| Professional | | $831.76 | $1,096.48 | $2,089.30 |