- 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 / $2,454.71 / $4,677.35
| Professional | | $2,041.74 | $2,454.71 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $10,471.29 / $19,498.45
| Facility | | $3,548.13 | $10,471.29 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,511.89 / $4,786.30
| Professional | | $1,819.70 | $2,511.89 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $3,890.45 / $10,964.78
| Facility | | $323.59 | $3,890.45 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,019.95 / $6,309.57
| Professional | | $1,819.70 | $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 |