- 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
- $1,819.70 / $2,238.72 / $4,466.84
| Professional | | $1,819.70 | $2,238.72 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $12,882.50 / $28,840.32
| Facility | | $4,466.84 | $12,882.50 | $28,840.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,691.53 / $5,128.61
| Professional | | $1,778.28 | $2,691.53 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,370.32 / $14,791.08
| Facility | | $323.59 | $5,370.32 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,090.30 / $6,165.95
| Professional | | $1,949.84 | $3,090.30 | $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
- $1,778.28 / $2,570.40 / $4,677.35
| Professional | | $1,778.28 | $2,570.40 | $4,677.35 |