- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $4,677.35 / $10,964.78
| Facility | | $1,380.38 | $4,677.35 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,659.59 / $2,344.23
| Professional | | $1,096.48 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $7,585.78 / $15,488.17
| Facility | | $3,388.44 | $7,585.78 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $1,659.59 / $3,311.31
| Professional | | $173.78 | $1,659.59 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,691.53 / $5,011.87
| Facility | | $2,187.76 | $2,691.53 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,801.89 / $7,585.78
| Professional | | $2,187.76 | $3,801.89 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,495.41 / $12,302.69
| Facility | | $1,905.46 | $5,495.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,570.40 / $4,466.84
| Professional | | $1,737.80 | $2,570.40 | $4,466.84 |