- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $4,570.88 / $11,481.54
| Facility | | $1,513.56 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $3,890.45
| Professional | | $1,348.96 | $1,698.24 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $12,022.64 / $26,915.35
| Facility | | $4,466.84 | $12,022.64 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $2,089.30 / $3,890.45
| Professional | | $1,348.96 | $2,089.30 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,630.78 / $10,232.93
| Facility | | $398.11 | $3,630.78 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,344.23 / $5,128.61
| Professional | | $1,479.11 | $2,344.23 | $5,128.61 |
- 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
- $1,348.96 / $1,949.84 / $3,630.78
| Professional | | $1,348.96 | $1,949.84 | $3,630.78 |