- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $4,677.35 / $11,220.18
| Facility | | $1,778.28 | $4,677.35 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $4,677.35
| Professional | | $1,737.80 | $2,089.30 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $12,022.64 / $25,118.86
| Facility | | $4,168.69 | $12,022.64 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $4,897.79
| Professional | | $1,737.80 | $2,630.27 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $549.54 / $4,677.35 / $13,182.57
| Facility | | $549.54 | $4,677.35 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $3,019.95 / $6,606.93
| Professional | | $1,905.46 | $3,019.95 | $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
- $1,737.80 / $2,511.89 / $4,677.35
| Professional | | $1,737.80 | $2,511.89 | $4,677.35 |