- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,754.40 / $14,454.40
| Facility | | $1,659.59 | $5,754.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $3,801.89
| Professional | | $1,348.96 | $1,621.81 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $10,471.29 / $19,498.45
| Facility | | $3,548.13 | $10,471.29 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,698.24 / $3,467.37
| Professional | | $1,096.48 | $1,698.24 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,897.79 / $13,803.84
| Facility | | $398.11 | $4,897.79 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,290.87 / $5,495.41
| Professional | | $1,445.44 | $2,290.87 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $6,918.31 / $15,488.17
| Facility | | $2,398.83 | $6,918.31 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $3,090.30
| Professional | | $1,047.13 | $1,584.89 | $3,090.30 |