- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,571.84 / $8,929.60 / $38,549.00
| Facility | | $3,571.84 | $8,929.60 | $38,549.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,571.84 / $5,256.68 / $5,728.43
| Professional | | $3,571.84 | $5,256.68 | $5,728.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,587.70 / $9,955.79 / $21,221.50
| Facility | | $6,587.70 | $9,955.79 | $21,221.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,076.30 / $8,828.52 / $12,279.06
| Professional | | $7,076.30 | $8,828.52 | $12,279.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,717.53 / $4,717.53 / $8,702.00
| Facility | | $4,717.53 | $4,717.53 | $8,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,717.53 / $4,717.53 / $4,717.53
| Professional | | $4,717.53 | $4,717.53 | $4,717.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,796.75 / $4,043.60 / $6,874.12
| Professional | | $2,796.75 | $4,043.60 | $6,874.12 |