- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,046.63 / $4,506.47 / $4,650.78
| Facility | | $3,046.63 | $4,506.47 | $4,650.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,046.63 / $3,490.93 / $6,347.15
| Professional | | $3,046.63 | $3,490.93 | $6,347.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,668.47 / $7,001.89 / $30,781.66
| Facility | | $6,668.47 | $7,001.89 | $30,781.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,254.14 / $3,643.96 / $5,397.59
| Professional | | $3,254.14 | $3,643.96 | $5,397.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,052.23 / $4,052.23 / $4,052.23
| Facility | | $4,052.23 | $4,052.23 | $4,052.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,958.13 / $2,958.13 / $4,173.80
| Professional | | $2,958.13 | $2,958.13 | $4,173.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,046.63 / $5,374.23 / $29,802.90
| Facility | | $3,046.63 | $5,374.23 | $29,802.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.71 / $3,564.54 / $5,580.24
| Professional | | $2,320.71 | $3,564.54 | $5,580.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,320.71 / $3,326.82 / $4,722.28
| Professional | | $2,320.71 | $3,326.82 | $4,722.28 |