- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,570.88 / $11,220.18
| Facility | | $1,513.56 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $3,548.13
| Professional | | $1,288.25 | $1,621.81 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $11,481.54 / $22,387.21
| Facility | | $4,073.80 | $11,481.54 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,995.26 / $3,630.78
| Professional | | $1,258.93 | $1,995.26 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,630.78 / $10,232.93
| Facility | | $398.11 | $3,630.78 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $4,677.35
| Professional | | $1,380.38 | $2,187.76 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $851.14 / $3,162.28 / $10,232.93
| Facility | | $851.14 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $3,235.94
| Professional | | $1,230.27 | $1,737.80 | $3,235.94 |