- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,715.35 / $9,772.37
| Facility | | $1,148.15 | $3,715.35 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,047.13 / $2,454.71
| Professional | | $891.25 | $1,047.13 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $7,943.28 / $16,982.44
| Facility | | $3,235.94 | $7,943.28 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,202.26 / $2,454.71
| Professional | | $812.83 | $1,202.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,630.27 / $7,244.36
| Facility | | $398.11 | $2,630.27 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,445.44 / $3,162.28
| Professional | | $891.25 | $1,445.44 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $7,244.36 / $17,378.01
| Facility | | $2,454.71 | $7,244.36 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,187.76
| Professional | | $812.83 | $1,174.90 | $2,187.76 |