- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $5,754.40 / $14,125.38
| Facility | | $1,380.38 | $5,754.40 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $954.99 / $2,187.76
| Professional | | $812.83 | $954.99 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $10,715.19 / $20,417.38
| Facility | | $3,715.35 | $10,715.19 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $2,238.72
| Professional | | $812.83 | $1,174.90 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $3,311.31 / $8,128.31
| Facility | | $1,513.56 | $3,311.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,380.38 / $3,019.95
| Professional | | $851.14 | $1,380.38 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $7,244.36 / $16,218.10
| Facility | | $2,511.89 | $7,244.36 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,096.48 / $2,041.74
| Professional | | $758.58 | $1,096.48 | $2,041.74 |