- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $8,511.38 / $12,302.69
| Facility | | $4,466.84 | $8,511.38 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $870.96 / $2,511.89
| Professional | | $758.58 | $870.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,174.90 / $2,454.71
| Professional | | $758.58 | $1,174.90 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,096.48 / $1,445.44
| Professional | | $812.83 | $1,096.48 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,456.54 / $10,232.93 / $16,218.10
| Facility | | $6,456.54 | $10,232.93 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,047.13 / $2,089.30
| Professional | | $707.95 | $1,047.13 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $6,606.93 / $10,964.78
| Facility | | $2,951.21 | $6,606.93 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,819.70
| Professional | | $758.58 | $1,023.29 | $1,819.70 |