- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,570.88 / $11,481.54
| Facility | | $1,412.54 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,445.44 / $2,951.21
| Professional | | $1,230.27 | $1,445.44 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $12,589.25 / $23,442.29
| Facility | | $4,466.84 | $12,589.25 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,819.70 / $3,467.37
| Professional | | $1,258.93 | $1,819.70 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,548.13 / $10,232.93
| Facility | | $398.11 | $3,548.13 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,137.96 / $4,570.88
| Professional | | $1,318.26 | $2,137.96 | $4,570.88 |
- 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
- $1,202.26 / $1,737.80 / $3,162.28
| Professional | | $1,202.26 | $1,737.80 | $3,162.28 |