- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $4,570.88 / $11,220.18
| Facility | | $1,584.89 | $4,570.88 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,737.80 / $3,467.37
| Professional | | $1,445.44 | $1,737.80 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $11,481.54 / $21,877.62
| Facility | | $4,073.80 | $11,481.54 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,949.84 / $3,630.78
| Professional | | $1,318.26 | $1,949.84 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,466.84 / $12,882.50
| Facility | | $323.59 | $4,466.84 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,290.87 / $5,011.87
| Professional | | $1,445.44 | $2,290.87 | $5,011.87 |
- 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
- $1,318.26 / $1,862.09 / $3,548.13
| Professional | | $1,318.26 | $1,862.09 | $3,548.13 |