- 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
- $1,862.09 / $2,290.87 / $4,570.88
| Professional | | $1,862.09 | $2,290.87 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $10,964.78 / $22,908.68
| Facility | | $4,073.80 | $10,964.78 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,754.23 / $5,370.32
| Professional | | $1,548.82 | $2,754.23 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $5,370.32 / $15,488.17
| Facility | | $398.11 | $5,370.32 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,090.30 / $6,456.54
| Professional | | $1,949.84 | $3,090.30 | $6,456.54 |
- 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 / $2,570.40 / $4,677.35
| Professional | | $1,819.70 | $2,570.40 | $4,677.35 |