- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $5,623.41 / $14,125.38
| Facility | | $1,584.89 | $5,623.41 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,348.96 / $2,951.21
| Professional | | $1,096.48 | $1,348.96 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $8,511.38 / $16,218.10
| Facility | | $3,311.31 | $8,511.38 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,621.81 / $3,019.95
| Professional | | $1,096.48 | $1,621.81 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $3,548.13 / $10,232.93
| Facility | | $323.59 | $3,548.13 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $3,890.45
| Professional | | $1,148.15 | $1,819.70 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $5,623.41 / $12,302.69
| Facility | | $1,905.46 | $5,623.41 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,479.11 / $2,754.23
| Professional | | $1,047.13 | $1,479.11 | $2,754.23 |