- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $5,754.40 / $14,454.40
| Facility | | $1,862.09 | $5,754.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $3,981.07
| Professional | | $1,659.59 | $1,905.46 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $11,481.54 / $22,387.21
| Facility | | $3,801.89 | $11,481.54 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,398.83 / $4,570.88
| Professional | | $1,659.59 | $2,398.83 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,466.84 / $12,589.25
| Facility | | $323.59 | $4,466.84 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,691.53 / $5,623.41
| Professional | | $1,778.28 | $2,691.53 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $11,481.54 / $28,840.32
| Facility | | $3,548.13 | $11,481.54 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,187.76 / $3,981.07
| Professional | | $1,548.82 | $2,187.76 | $3,981.07 |