- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,570.88 / $11,481.54
| Facility | | $1,737.80 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,089.30 / $5,623.41
| Professional | | $1,659.59 | $2,089.30 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $12,589.25 / $28,840.32
| Facility | | $4,466.84 | $12,589.25 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,398.83 / $4,570.88
| Professional | | $1,380.38 | $2,398.83 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,466.84 / $11,481.54
| Facility | | $398.11 | $4,466.84 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,818.38 / $5,623.41
| Professional | | $1,737.80 | $2,818.38 | $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
- $1,621.81 / $2,290.87 / $4,168.69
| Professional | | $1,621.81 | $2,290.87 | $4,168.69 |