- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $4,677.35 / $11,481.54
| Facility | | $1,737.80 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,949.84 / $4,265.80
| Professional | | $1,621.81 | $1,949.84 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $12,302.69 / $24,547.09
| Facility | | $4,677.35 | $12,302.69 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,398.83 / $4,677.35
| Professional | | $1,621.81 | $2,398.83 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $3,890.45 / $14,791.08
| Facility | | $602.56 | $3,890.45 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,691.53 / $5,754.40
| Professional | | $1,778.28 | $2,691.53 | $5,754.40 |
- 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
- $1,548.82 / $2,187.76 / $4,073.80
| Professional | | $1,548.82 | $2,187.76 | $4,073.80 |