- 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 / $4,786.30
| Professional | | $1,862.09 | $2,290.87 | $4,786.30 |
- 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 / $2,884.03 / $5,370.32
| Professional | | $1,819.70 | $2,884.03 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,623.41 / $15,488.17
| Facility | | $323.59 | $5,623.41 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,235.94 / $6,456.54
| Professional | | $1,995.26 | $3,235.94 | $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 / $2,630.27 / $4,786.30
| Professional | | $1,819.70 | $2,630.27 | $4,786.30 |