- 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
- $3,890.45 / $10,964.78 / $20,892.96
| Facility | | $3,890.45 | $10,964.78 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,691.53 / $5,248.07
| Professional | | $1,778.28 | $2,691.53 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,786.30 / $12,302.69
| Facility | | $398.11 | $4,786.30 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $3,162.28 / $6,025.60
| Professional | | $1,949.84 | $3,162.28 | $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
- $1,778.28 / $2,630.27 / $4,677.35
| Professional | | $1,778.28 | $2,630.27 | $4,677.35 |