- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,570.88 / $11,748.98
| Facility | | $1,584.89 | $4,570.88 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,778.28 / $4,466.84
| Professional | | $1,479.11 | $1,778.28 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $13,182.57 / $26,302.68
| Facility | | $4,570.88 | $13,182.57 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $3,981.07
| Professional | | $1,380.38 | $2,137.96 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $3,715.35 / $11,748.98
| Facility | | $645.65 | $3,715.35 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,398.83 / $5,128.61
| Professional | | $1,584.89 | $2,398.83 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,019.95 / $8,709.64 / $19,054.61
| Facility | | $3,019.95 | $8,709.64 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,949.84 / $3,630.78
| Professional | | $1,380.38 | $1,949.84 | $3,630.78 |