- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $5,754.40 / $14,125.38
| Facility | | $1,445.44 | $5,754.40 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,023.29 / $2,454.71
| Professional | | $891.25 | $1,023.29 | $2,454.71 |
- 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
- $891.25 / $1,318.26 / $2,454.71
| Professional | | $891.25 | $1,318.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,019.95 / $7,244.36
| Facility | | $1,621.81 | $3,019.95 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,513.56 / $3,235.94
| Professional | | $933.25 | $1,513.56 | $3,235.94 |
- 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
- $851.14 / $1,202.26 / $2,238.72
| Professional | | $851.14 | $1,202.26 | $2,238.72 |