- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,570.88 / $11,481.54
| Facility | | $1,513.56 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,621.81 / $3,235.94
| Professional | | $1,288.25 | $1,621.81 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $10,232.93 / $20,892.96
| Facility | | $3,548.13 | $10,232.93 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,995.26 / $3,890.45
| Professional | | $1,071.52 | $1,995.26 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $3,981.07 / $13,803.84
| Facility | | $794.33 | $3,981.07 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $4,570.88
| Professional | | $1,380.38 | $2,187.76 | $4,570.88 |
- 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
- $1,258.93 / $1,778.28 / $3,311.31
| Professional | | $1,258.93 | $1,778.28 | $3,311.31 |