- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,570.88 / $11,481.54
| Facility | | $1,412.54 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $3,019.95
| Professional | | $1,230.27 | $1,445.44 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $8,912.51 / $16,982.44
| Facility | | $3,388.44 | $8,912.51 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,778.28 / $3,388.44
| Professional | | $1,230.27 | $1,778.28 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,818.38 / $9,772.37
| Facility | | $398.11 | $2,818.38 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,995.26 / $4,265.80
| Professional | | $1,348.96 | $1,995.26 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $8,912.51 / $20,892.96
| Facility | | $2,884.03 | $8,912.51 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,621.81 / $3,019.95
| Professional | | $1,148.15 | $1,621.81 | $3,019.95 |