- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,570.88 / $10,715.19
| Facility | | $2,884.03 | $4,570.88 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,344.23 / $2,754.23
| Professional | | $1,905.46 | $2,344.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $8,709.64
| Facility | | $2,884.03 | $2,884.03 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,174.90 / $2,344.23
| Professional | | $851.14 | $1,174.90 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $42,657.95 / $63,095.73
| Facility | | $2,818.38 | $42,657.95 | $63,095.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $3,548.13 / $8,709.64
| Professional | | $1,548.82 | $3,548.13 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,884.03
| Professional | | $1,230.27 | $1,737.80 | $2,884.03 |