- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $4,365.16 / $10,715.19
| Facility | | $1,202.26 | $4,365.16 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,023.29 / $1,995.26
| Professional | | $812.83 | $1,023.29 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $6,309.57 / $12,302.69
| Facility | | $2,454.71 | $6,309.57 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,202.26 / $2,238.72
| Professional | | $794.33 | $1,202.26 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.96 / $2,290.87 / $6,760.83
| Facility | | $870.96 | $2,290.87 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,348.96 / $3,090.30
| Professional | | $794.33 | $1,348.96 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,168.69 / $9,549.93
| Facility | | $1,445.44 | $4,168.69 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,023.29 / $1,905.46
| Professional | | $758.58 | $1,023.29 | $1,905.46 |