- 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 / $2,290.87 / $5,248.07
| Professional | | $1,819.70 | $2,290.87 | $5,248.07 |
- 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
- $1,862.09 / $2,818.38 / $5,248.07
| Professional | | $1,862.09 | $2,818.38 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $5,888.44 / $16,595.87
| Facility | | $323.59 | $5,888.44 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,235.94 / $6,918.31
| Professional | | $1,995.26 | $3,235.94 | $6,918.31 |
- 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
- $1,862.09 / $2,630.27 / $4,897.79
| Professional | | $1,862.09 | $2,630.27 | $4,897.79 |