- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $4,570.88 / $11,220.18
| Facility | | $1,548.82 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,621.81 / $3,235.94
| Professional | | $1,348.96 | $1,621.81 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $10,715.19 / $20,892.96
| Facility | | $3,981.07 | $10,715.19 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,862.09 / $3,548.13
| Professional | | $1,258.93 | $1,862.09 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,265.80 / $12,022.64
| Facility | | $323.59 | $4,265.80 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,187.76 / $4,786.30
| Professional | | $1,380.38 | $2,187.76 | $4,786.30 |
- 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
- $1,258.93 / $1,819.70 / $3,388.44
| Professional | | $1,258.93 | $1,819.70 | $3,388.44 |