- 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
- $1,621.81 / $1,949.84 / $4,365.16
| Professional | | $1,621.81 | $1,949.84 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,302.69 / $25,118.86
| Facility | | $4,677.35 | $12,302.69 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $4,570.88
| Professional | | $1,584.89 | $2,290.87 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,388.44 / $12,589.25
| Facility | | $398.11 | $3,388.44 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $5,754.40
| Professional | | $1,737.80 | $2,630.27 | $5,754.40 |
- 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
- $1,513.56 / $2,137.96 / $3,981.07
| Professional | | $1,513.56 | $2,137.96 | $3,981.07 |