- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $4,677.35 / $11,481.54
| Facility | | $1,445.44 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,584.89 / $3,548.13
| Professional | | $1,288.25 | $1,584.89 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,302.69 / $24,547.09
| Facility | | $4,677.35 | $12,302.69 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,187.76 / $3,801.89
| Professional | | $1,412.54 | $2,187.76 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,019.95 / $10,232.93
| Facility | | $398.11 | $3,019.95 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,238.72 / $4,677.35
| Professional | | $1,412.54 | $2,238.72 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,162.28 / $10,232.93
| Facility | | $812.83 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,778.28 / $3,311.31
| Professional | | $1,258.93 | $1,778.28 | $3,311.31 |