- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,873.00 / $7,087.59 / $9,568.25
| Facility | | $3,873.00 | $7,087.59 | $9,568.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,059.67 / $7,087.59 / $7,862.19
| Professional | | $3,059.67 | $7,087.59 | $7,862.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,896.46 / $3,896.46 / $3,896.46
| Facility | | $3,896.46 | $3,896.46 | $3,896.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,896.46 / $3,896.46 / $3,896.46
| Professional | | $3,896.46 | $3,896.46 | $3,896.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,517.44 / $2,643.32 / $3,247.51
| Facility | | $2,517.44 | $2,643.32 | $3,247.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,657.70 / $2,983.86 / $6,630.81
| Professional | | $1,657.70 | $2,983.86 | $6,630.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,077.48 / $3,077.48 / $3,873.00
| Facility | | $3,077.48 | $3,077.48 | $3,873.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,436.16 / $2,051.65 / $5,809.50
| Professional | | $1,436.16 | $2,051.65 | $5,809.50 |