- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,570.88 / $11,481.54
| Facility | | $1,412.54 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,412.54 / $2,691.53
| Professional | | $1,202.26 | $1,412.54 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,801.89 / $11,481.54 / $22,387.21
| Facility | | $3,801.89 | $11,481.54 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,659.59 / $2,951.21
| Professional | | $1,202.26 | $1,659.59 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,238.72 / $5,754.40
| Facility | | $398.11 | $2,238.72 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $3,630.78
| Professional | | $1,202.26 | $1,905.46 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,818.38 / $9,772.37
| Facility | | $537.03 | $2,818.38 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $2,884.03
| Professional | | $1,148.15 | $1,659.59 | $2,884.03 |