- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,011.87 / $15,135.61
| Facility | | $3,715.35 | $5,011.87 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,365.16 / $5,495.41
| Professional | | $3,715.35 | $4,365.16 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $13,489.63
| Facility | | $3,235.94 | $3,235.94 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $7,244.36
| Professional | | $6,025.60 | $6,025.60 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,011.87 / $8,709.64
| Facility | | $3,715.35 | $5,011.87 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $18,620.87
| Professional | | $2,089.30 | $2,089.30 | $18,620.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,089.30 / $5,011.87 / $6,025.60
| Facility | | $2,089.30 | $5,011.87 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $3,311.31
| Professional | | $2,089.30 | $2,089.30 | $3,311.31 |