- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,031.20 / $5,031.20 / $12,578.00
| Facility | | $5,031.20 | $5,031.20 | $12,578.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,031.20 / $5,031.20 / $5,031.20
| Professional | | $5,031.20 | $5,031.20 | $5,031.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.48 / $2,213.71 / $3,270.28
| Professional | | $2,012.48 | $2,213.71 | $3,270.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,731.42 / $10,731.42 / $10,731.42
| Facility | | $10,731.42 | $10,731.42 | $10,731.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,186.94 / $5,091.55 / $5,316.91
| Professional | | $3,186.94 | $5,091.55 | $5,316.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,031.20 / $5,031.20 / $5,081.51
| Professional | | $5,031.20 | $5,031.20 | $5,081.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,031.20 / $5,031.20 / $12,578.00
| Facility | | $5,031.20 | $5,031.20 | $12,578.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,031.20 / $5,031.20 / $5,031.20
| Professional | | $5,031.20 | $5,031.20 | $5,031.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,018.72 / $3,018.72 / $8,804.60
| Professional | | $3,018.72 | $3,018.72 | $8,804.60 |