- 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
- $1,202.26 / $1,513.56 / $3,630.78
| Professional | | $1,202.26 | $1,513.56 | $3,630.78 |
- 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
- $1,230.27 / $1,862.09 / $3,548.13
| Professional | | $1,230.27 | $1,862.09 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,311.31 / $9,120.11
| Facility | | $398.11 | $3,311.31 | $9,120.11 |
- 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
- $1,230.27 / $1,737.80 / $3,235.94
| Professional | | $1,230.27 | $1,737.80 | $3,235.94 |