- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $9,120.11 / $16,595.87
| Facility | | $1,862.09 | $9,120.11 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,905.46 / $2,630.27
| Professional | | $1,047.13 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $5,128.61 / $9,120.11
| Facility | | $2,398.83 | $5,128.61 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,311.31 / $7,585.78
| Facility | | $1,737.80 | $3,311.31 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9,120.11 / $9,120.11 / $9,120.11
| Professional | | $9,120.11 | $9,120.11 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,238.72 / $3,467.37
| Facility | | $1,258.93 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $13,182.57 / $23,988.33
| Facility | | $2,344.23 | $13,182.57 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,230.27 / $2,454.71
| Professional | | $562.34 | $1,230.27 | $2,454.71 |