- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.00 / $6,130.09 / $6,520.11
| Facility | | $144.00 | $6,130.09 | $6,520.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,904.07 / $4,904.07 / $6,130.09
| Professional | | $4,904.07 | $4,904.07 | $6,130.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.00 / $204.37 / $475.73
| Facility | | $154.00 | $204.37 | $475.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Facility | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,210.58 / $5,210.58 / $5,210.58
| Professional | | $5,210.58 | $5,210.58 | $5,210.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,074.81 / $5,405.72 / $7,707.36
| Facility | | $2,074.81 | $5,405.72 | $7,707.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $22,185.08
| Professional | | $5,108.41 | $5,108.41 | $22,185.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,108.41 / $5,108.41 / $6,130.09
| Professional | | $5,108.41 | $5,108.41 | $6,130.09 |