- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,035.10 / $5,610.54 / $34,112.10
| Facility | | $5,035.10 | $5,610.54 | $34,112.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,610.54 / $5,610.54 / $7,193.00
| Professional | | $5,610.54 | $5,610.54 | $7,193.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,193.00 / $7,193.00 / $9,926.34
| Professional | | $7,193.00 | $7,193.00 | $9,926.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13,072.56 / $17,719.96 / $41,013.05
| Facility | | $13,072.56 | $17,719.96 | $41,013.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,265.58 / $3,507.67 / $9,766.79
| Professional | | $3,265.58 | $3,507.67 | $9,766.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,610.54 / $7,193.00 / $10,429.85
| Facility | | $5,610.54 | $7,193.00 | $10,429.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.06 / $4,315.80 / $6,550.02
| Professional | | $3,021.06 | $4,315.80 | $6,550.02 |