- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $4,570.88 / $11,481.54
| Facility | | $1,122.02 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,023.29 / $2,290.87
| Professional | | $851.14 | $1,023.29 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $7,585.78 / $15,848.93
| Facility | | $2,818.38 | $7,585.78 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,258.93 / $2,398.83
| Professional | | $831.76 | $1,258.93 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,398.83 / $6,760.83
| Facility | | $398.11 | $2,398.83 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,479.11 / $3,311.31
| Professional | | $912.01 | $1,479.11 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $1,202.26 / $2,290.87
| Professional | | $831.76 | $1,202.26 | $2,290.87 |