- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $4,570.88 / $12,302.69
| Facility | | $1,621.81 | $4,570.88 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $4,365.16
| Professional | | $1,737.80 | $2,137.96 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $14,454.40 / $28,840.32
| Facility | | $4,265.80 | $14,454.40 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,630.27 / $4,897.79
| Professional | | $1,698.24 | $2,630.27 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,248.07 / $14,454.40
| Facility | | $323.59 | $5,248.07 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,951.21 / $6,025.60
| Professional | | $1,819.70 | $2,951.21 | $6,025.60 |
- 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
- $1,698.24 / $2,398.83 / $4,365.16
| Professional | | $1,698.24 | $2,398.83 | $4,365.16 |