- 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 / $4,897.79
| Professional | | $1,819.70 | $2,238.72 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $12,022.64 / $25,118.86
| Facility | | $4,265.80 | $12,022.64 | $25,118.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,818.38 / $5,128.61
| Professional | | $1,862.09 | $2,818.38 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,897.79 / $14,125.38
| Facility | | $398.11 | $4,897.79 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,235.94 / $7,079.46
| Professional | | $1,995.26 | $3,235.94 | $7,079.46 |
- 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
- $1,819.70 / $2,630.27 / $5,011.87
| Professional | | $1,819.70 | $2,630.27 | $5,011.87 |