- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,244.36 / $8,912.51
| Facility | | $4,570.88 | $7,244.36 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $7,079.46 / $9,549.93
| Professional | | $4,570.88 | $7,079.46 | $9,549.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $22,387.21
| Facility | | $794.33 | $794.33 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $8,912.51 / $12,302.69
| Professional | | $4,570.88 | $8,912.51 | $12,302.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $7,413.10 / $17,378.01
| Professional | | $891.25 | $7,413.10 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,230.27 / $5,370.32
| Facility | | $371.54 | $1,230.27 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,890.45 / $6,760.83
| Professional | | $2,630.27 | $3,890.45 | $6,760.83 |