- 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
- $1,778.28 / $2,089.30 / $4,786.30
| Professional | | $1,778.28 | $2,089.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $13,489.63 / $28,183.83
| Facility | | $4,677.35 | $13,489.63 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,754.23 / $5,128.61
| Professional | | $1,778.28 | $2,754.23 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,623.41 / $15,848.93
| Facility | | $323.59 | $5,623.41 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,090.30 / $6,606.93
| Professional | | $1,905.46 | $3,090.30 | $6,606.93 |
- 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 / $2,511.89 / $4,786.30
| Professional | | $1,778.28 | $2,511.89 | $4,786.30 |