- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,570.88 / $11,481.54
| Facility | | $1,778.28 | $4,570.88 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $5,248.07
| Professional | | $1,778.28 | $2,187.76 | $5,248.07 |
- 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
- $1,737.80 / $2,691.53 / $5,011.87
| Professional | | $1,737.80 | $2,691.53 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,897.79 / $12,302.69
| Facility | | $398.11 | $4,897.79 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,019.95 / $6,165.95
| Professional | | $1,862.09 | $3,019.95 | $6,165.95 |
- 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
- $1,737.80 / $2,454.71 / $4,466.84
| Professional | | $1,737.80 | $2,454.71 | $4,466.84 |