- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,570.88 / $11,481.54
| Facility | | $1,445.44 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,513.56 / $3,467.37
| Professional | | $1,202.26 | $1,513.56 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $13,489.63 / $28,183.83
| Facility | | $4,677.35 | $13,489.63 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,778.28 / $3,467.37
| Professional | | $1,202.26 | $1,778.28 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $4,168.69 / $12,022.64
| Facility | | $323.59 | $4,168.69 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,137.96 / $4,897.79
| Professional | | $1,258.93 | $2,137.96 | $4,897.79 |
- 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
- $1,174.90 / $1,737.80 / $3,388.44
| Professional | | $1,174.90 | $1,737.80 | $3,388.44 |