- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,677.35 / $11,481.54
| Facility | | $1,819.70 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,454.71 / $5,248.07
| Professional | | $1,995.26 | $2,454.71 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $10,964.78 / $21,877.62
| Facility | | $3,981.07 | $10,964.78 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $5,248.07
| Professional | | $1,819.70 | $2,691.53 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $6,606.93 / $19,054.61
| Facility | | $323.59 | $6,606.93 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,235.94 / $7,079.46
| Professional | | $1,949.84 | $3,235.94 | $7,079.46 |
- 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
- $1,819.70 / $2,630.27 / $4,897.79
| Professional | | $1,819.70 | $2,630.27 | $4,897.79 |