- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $4,786.30 / $11,748.98
| Facility | | $1,819.70 | $4,786.30 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,187.76 / $4,786.30
| Professional | | $1,819.70 | $2,187.76 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,302.69 / $26,915.35
| Facility | | $4,677.35 | $12,302.69 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,630.27 / $5,248.07
| Professional | | $1,819.70 | $2,630.27 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $5,623.41 / $15,488.17
| Facility | | $398.11 | $5,623.41 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $3,019.95 / $6,456.54
| Professional | | $1,995.26 | $3,019.95 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $3,162.28 / $10,232.93
| Facility | | $812.83 | $3,162.28 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,454.71 / $4,570.88
| Professional | | $1,737.80 | $2,454.71 | $4,570.88 |