- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,677.35 / $11,481.54
| Facility | | $1,737.80 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $4,265.80
| Professional | | $1,659.59 | $1,949.84 | $4,265.80 |
- 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
- $1,659.59 / $2,454.71 / $4,677.35
| Professional | | $1,659.59 | $2,454.71 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,248.07 / $14,791.08
| Facility | | $323.59 | $5,248.07 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,884.03 / $6,165.95
| Professional | | $1,778.28 | $2,884.03 | $6,165.95 |
- 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
- $1,659.59 / $2,344.23 / $4,466.84
| Professional | | $1,659.59 | $2,344.23 | $4,466.84 |