- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,365.16 / $14,791.08
| Facility | | $3,162.28 | $4,365.16 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $4,073.80
| Professional | | $3,162.28 | $3,162.28 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,760.83 / $11,220.18 / $15,848.93
| Facility | | $6,760.83 | $11,220.18 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,818.38 / $4,466.84
| Professional | | $2,187.76 | $2,818.38 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,311.31 / $6,606.93
| Facility | | $3,162.28 | $3,311.31 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,248.07 / $10,964.78
| Facility | | $1,737.80 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $5,248.07 / $10,964.78
| Professional | | $1,737.80 | $5,248.07 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $3,019.95 / $6,309.57
| Facility | | $407.38 | $3,019.95 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Professional | | $1,737.80 | $1,737.80 | $1,737.80 |