- 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
- $1,479.11 / $1,778.28 / $3,388.44
| Professional | | $1,479.11 | $1,778.28 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $8,912.51 / $16,982.44
| Facility | | $3,388.44 | $8,912.51 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,778.28 / $3,467.37
| Professional | | $1,348.96 | $1,778.28 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $2,818.38 / $6,760.83
| Facility | | $398.11 | $2,818.38 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,187.76 / $4,570.88
| Professional | | $1,348.96 | $2,187.76 | $4,570.88 |
- 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
- $1,348.96 / $1,862.09 / $3,388.44
| Professional | | $1,348.96 | $1,862.09 | $3,388.44 |