- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,897.79 / $11,481.54
| Facility | | $1,659.59 | $4,897.79 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,659.59 / $3,548.13
| Professional | | $1,445.44 | $1,659.59 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $9,772.37 / $17,782.79
| Facility | | $3,467.37 | $9,772.37 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $3,890.45
| Professional | | $1,445.44 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,365.16 / $11,481.54
| Facility | | $323.59 | $4,365.16 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,344.23 / $5,011.87
| Professional | | $1,513.56 | $2,344.23 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,344.23 / $7,244.36 / $16,595.87
| Facility | | $2,344.23 | $7,244.36 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,862.09 / $3,467.37
| Professional | | $1,348.96 | $1,862.09 | $3,467.37 |