- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,966.19 / $4,691.20 / $8,095.94
| Facility | | $2,966.19 | $4,691.20 | $8,095.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,966.19 / $3,035.98 / $3,384.94
| Professional | | $2,966.19 | $3,035.98 | $3,384.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $3,114.49 / $6,180.67
| Professional | | $200.00 | $3,114.49 | $6,180.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,806.43 / $6,739.00 / $8,317.70
| Facility | | $4,806.43 | $6,739.00 | $8,317.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,677.28 / $3,677.28 / $3,677.28
| Professional | | $3,677.28 | $3,677.28 | $3,677.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,966.19 / $4,187.56 / $16,575.74
| Facility | | $2,966.19 | $4,187.56 | $16,575.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $2,093.78 / $17,378.36
| Professional | | $1,465.64 | $2,093.78 | $17,378.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,465.64 / $2,093.78 / $3,946.77
| Professional | | $1,465.64 | $2,093.78 | $3,946.77 |