- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $4,570.88 / $11,220.18
| Facility | | $1,348.96 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $2,511.89
| Professional | | $1,122.02 | $1,348.96 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $9,332.54 / $17,378.01
| Facility | | $3,548.13 | $9,332.54 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,348.96 / $2,630.27
| Professional | | $1,047.13 | $1,348.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $2,137.96 / $7,762.47
| Facility | | $323.59 | $2,137.96 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,659.59 / $3,467.37
| Professional | | $1,023.29 | $1,659.59 | $3,467.37 |
- 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
- $1,023.29 / $1,412.54 / $2,570.40
| Professional | | $1,023.29 | $1,412.54 | $2,570.40 |