- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,570.88 / $11,220.18
| Facility | | $1,584.89 | $4,570.88 | $11,220.18 |
- 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
- $3,388.44 / $8,912.51 / $16,982.44
| Facility | | $3,388.44 | $8,912.51 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,137.96 / $3,981.07
| Professional | | $1,445.44 | $2,137.96 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,311.31 / $11,481.54
| Facility | | $398.11 | $3,311.31 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,398.83 / $5,011.87
| Professional | | $1,584.89 | $2,398.83 | $5,011.87 |
- 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
- $1,348.96 / $1,905.46 / $3,548.13
| Professional | | $1,348.96 | $1,905.46 | $3,548.13 |