- 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
- $1,737.80 / $2,137.96 / $4,677.35
| Professional | | $1,737.80 | $2,137.96 | $4,677.35 |
- 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
- $1,698.24 / $2,511.89 / $4,897.79
| Professional | | $1,698.24 | $2,511.89 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $4,786.30 / $14,125.38
| Facility | | $398.11 | $4,786.30 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $3,019.95 / $6,918.31
| Professional | | $1,778.28 | $3,019.95 | $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
- $1,659.59 / $2,454.71 / $4,786.30
| Professional | | $1,659.59 | $2,454.71 | $4,786.30 |