- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $5,754.40 / $14,454.40
| Facility | | $1,659.59 | $5,754.40 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $3,890.45
| Professional | | $1,412.54 | $1,698.24 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,754.23 / $3,890.45
| Professional | | $1,698.24 | $2,754.23 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,290.87 / $3,801.89
| Professional | | $1,621.81 | $2,290.87 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,041.74 / $3,162.28
| Facility | | $1,479.11 | $2,041.74 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.01 / $2,884.03 / $4,168.69
| Professional | | $5.01 | $2,884.03 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $12,302.69 / $19,054.61
| Facility | | $4,466.84 | $12,302.69 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $3,388.44
| Professional | | $1,412.54 | $1,862.09 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,595.87 / $16,595.87 / $33,884.42
| Facility | | $16,595.87 | $16,595.87 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $13,182.57
| Professional | | $11,220.18 | $11,220.18 | $13,182.57 |