- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $4,677.35 / $11,481.54
| Facility | | $1,659.59 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,819.70 / $3,548.13
| Professional | | $1,548.82 | $1,819.70 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $11,481.54 / $22,387.21
| Facility | | $4,073.80 | $11,481.54 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,290.87 / $4,265.80
| Professional | | $1,584.89 | $2,290.87 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,248.07 / $15,135.61
| Facility | | $323.59 | $5,248.07 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $2,691.53 / $5,754.40
| Professional | | $1,659.59 | $2,691.53 | $5,754.40 |
- 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
- $1,513.56 / $2,187.76 / $3,981.07
| Professional | | $1,513.56 | $2,187.76 | $3,981.07 |