- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,623.41 / $13,182.57
| Facility | | $3,630.78 | $5,623.41 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $3,388.44
| Professional | | $2,344.23 | $2,951.21 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $10,715.19
| Facility | | $3,630.78 | $3,630.78 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $1,445.44 / $2,884.03
| Professional | | $851.14 | $1,445.44 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $52,480.75 / $77,624.71
| Facility | | $3,467.37 | $52,480.75 | $77,624.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $4,365.16 / $10,715.19
| Professional | | $1,905.46 | $4,365.16 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,137.96 / $3,630.78
| Professional | | $1,513.56 | $2,137.96 | $3,630.78 |