- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $4,677.35 / $11,481.54
| Facility | | $1,862.09 | $4,677.35 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,511.89 / $4,677.35
| Professional | | $2,041.74 | $2,511.89 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $9,332.54 / $17,378.01
| Facility | | $3,548.13 | $9,332.54 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,454.71 / $4,786.30
| Professional | | $1,862.09 | $2,454.71 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $3,981.07 / $9,120.11
| Facility | | $398.11 | $3,981.07 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $3,019.95 / $6,309.57
| Professional | | $1,862.09 | $3,019.95 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $537.03 / $2,818.38 / $9,772.37
| Facility | | $537.03 | $2,818.38 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,630.27 / $4,786.30
| Professional | | $1,862.09 | $2,630.27 | $4,786.30 |