- 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
- $1,949.84 / $2,398.83 / $4,897.79
| Professional | | $1,949.84 | $2,398.83 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $15,488.17 / $30,199.52
| Facility | | $4,897.79 | $15,488.17 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,754.23 / $5,370.32
| Professional | | $1,819.70 | $2,754.23 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,888.44 / $16,218.10
| Facility | | $323.59 | $5,888.44 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,311.31 / $6,760.83
| Professional | | $2,041.74 | $3,311.31 | $6,760.83 |
- 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 / $2,691.53 / $5,011.87
| Professional | | $1,819.70 | $2,691.53 | $5,011.87 |