- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,129.74 / $28,433.64 / $28,433.64
| Facility | | $3,129.74 | $28,433.64 | $28,433.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,725.03 / $3,372.57
| Professional | | $2,698.05 | $2,725.03 | $3,372.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,109.51 / $3,772.86 / $4,037.35
| Facility | | $3,109.51 | $3,772.86 | $4,037.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Professional | | $2,698.05 | $2,698.05 | $2,698.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $2,698.05 / $3,588.47
| Professional | | $60.00 | $2,698.05 | $3,588.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,242.54 / $5,447.21 / $7,594.67
| Facility | | $4,242.54 | $5,447.21 | $7,594.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,967.86 / $3,656.99 / $3,849.31
| Professional | | $2,967.86 | $3,656.99 | $3,849.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,698.05 / $2,698.05 / $2,698.05
| Professional | | $2,698.05 | $2,698.05 | $2,698.05 |