- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $5,248.07 / $12,022.64
| Facility | | $1,258.93 | $5,248.07 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $954.99 / $2,041.74
| Professional | | $794.33 | $954.99 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $10,471.29 / $20,417.38
| Facility | | $3,801.89 | $10,471.29 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,230.27 / $2,238.72
| Professional | | $794.33 | $1,230.27 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $2,290.87 / $6,456.54
| Facility | | $549.54 | $2,290.87 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,380.38 / $2,951.21
| Professional | | $870.96 | $1,380.38 | $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 / $2,041.74
| Professional | | $812.83 | $1,148.15 | $2,041.74 |