- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $4,570.88 / $11,220.18
| Facility | | $1,621.81 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,995.26 / $3,801.89
| Professional | | $1,584.89 | $1,995.26 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,511.38 / $18,197.01
| Facility | | $3,311.31 | $8,511.38 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $4,466.84
| Professional | | $1,621.81 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,466.84 / $11,748.98
| Facility | | $398.11 | $4,466.84 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,754.23 / $5,623.41
| Professional | | $1,737.80 | $2,754.23 | $5,623.41 |
- 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
- $1,584.89 / $2,344.23 / $4,168.69
| Professional | | $1,584.89 | $2,344.23 | $4,168.69 |