- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $3,467.37 / $4,897.79
| Facility | | $1,380.38 | $3,467.37 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,202.26 / $2,041.74
| Professional | | $891.25 | $1,202.26 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $8,709.64 / $11,220.18
| Facility | | $4,265.80 | $8,709.64 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,288.25 / $2,089.30
| Professional | | $851.14 | $1,288.25 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,148.15 / $1,288.25
| Facility | | $1,047.13 | $1,148.15 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.24 / $1,348.96 / $2,089.30
| Professional | | $977.24 | $1,348.96 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,715.35 / $6,456.54
| Facility | | $1,621.81 | $3,715.35 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,096.48 / $1,949.84
| Professional | | $851.14 | $1,096.48 | $1,949.84 |