- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,025.60 / $10,964.78
| Facility | | $3,890.45 | $6,025.60 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,047.13 / $2,238.72
| Professional | | $794.33 | $1,047.13 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,317.64 / $15,135.61 / $16,595.87
| Facility | | $8,317.64 | $15,135.61 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,659.59 / $2,137.96
| Professional | | $794.33 | $1,659.59 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.95 / $1,258.93 / $2,754.23
| Professional | | $707.95 | $1,258.93 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $933.25 / $1,412.54
| Professional | | $562.34 | $933.25 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,079.46 / $11,220.18
| Facility | | $4,570.88 | $7,079.46 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $954.99 / $2,398.83
| Professional | | $758.58 | $954.99 | $2,398.83 |