- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $9,772.37 / $17,378.01
| Facility | | $2,398.83 | $9,772.37 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,128.61 / $9,772.37
| Professional | | $4,466.84 | $5,128.61 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $10,964.78 / $16,982.44
| Facility | | $3,890.45 | $10,964.78 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,466.84 / $9,549.93 / $14,125.38
| Professional | | $4,466.84 | $9,549.93 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.83 / $7,413.10 / $13,182.57
| Professional | | $691.83 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $3,388.44 / $7,413.10
| Facility | | $446.68 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,128.61 / $7,413.10 / $11,748.98
| Professional | | $5,128.61 | $7,413.10 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $3,388.44 / $7,413.10
| Facility | | $446.68 | $3,388.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,413.10 / $13,182.57
| Professional | | $4,897.79 | $7,413.10 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,897.79 / $6,025.60
| Facility | | $3,548.13 | $4,897.79 | $6,025.60 |