- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,677.35 / $11,481.54
| Facility | | $1,778.28 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,137.96 / $4,677.35
| Professional | | $1,737.80 | $2,137.96 | $4,677.35 |
- 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 / $2,691.53 / $5,011.87
| Professional | | $1,698.24 | $2,691.53 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,677.35 / $12,022.64
| Facility | | $398.11 | $4,677.35 | $12,022.64 |
- 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 / $2,454.71 / $4,466.84
| Professional | | $1,698.24 | $2,454.71 | $4,466.84 |