- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $4,570.88 / $11,220.18
| Facility | | $1,698.24 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,949.84 / $3,981.07
| Professional | | $1,584.89 | $1,949.84 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $13,489.63 / $28,840.32
| Facility | | $4,570.88 | $13,489.63 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,398.83 / $4,466.84
| Professional | | $1,548.82 | $2,398.83 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,466.84 / $11,220.18
| Facility | | $398.11 | $4,466.84 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $5,495.41
| Professional | | $1,698.24 | $2,691.53 | $5,495.41 |
- 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
- $1,548.82 / $2,238.72 / $4,073.80
| Professional | | $1,548.82 | $2,238.72 | $4,073.80 |