- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,328.00 / $8,303.41 / $13,413.92
| Facility | | $5,328.00 | $8,303.41 | $13,413.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,406.21 / $2,406.21 / $3,007.77
| Professional | | $2,406.21 | $2,406.21 | $3,007.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,729.97 / $1,729.97 / $1,729.97
| Professional | | $1,729.97 | $1,729.97 | $1,729.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.21 / $3,368.71 / $3,440.89
| Facility | | $2,406.21 | $3,368.71 | $3,440.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.80 / $478.80 / $684.00
| Professional | | $478.80 | $478.80 | $684.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,406.21 / $3,368.71 / $3,440.89
| Facility | | $2,406.21 | $3,368.71 | $3,440.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.80 / $684.00 / $1,729.97
| Professional | | $478.80 | $684.00 | $1,729.97 |