- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.00 / $2,477.17 / $9,510.77
| Facility | | $758.00 | $2,477.17 | $9,510.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,477.17 / $2,831.06 / $2,857.82
| Professional | | $2,477.17 | $2,831.06 | $2,857.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $4,536.46
| Facility | | $4,536.46 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $4,536.46 / $4,536.46
| Professional | | $3,855.99 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.75 / $3,467.57 / $26,749.15
| Facility | | $1,652.75 | $3,467.57 | $26,749.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.73 / $3,383.01 / $5,844.60
| Professional | | $1,706.73 | $3,383.01 | $5,844.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,706.73 / $2,603.28 / $3,856.41
| Professional | | $1,706.73 | $2,603.28 | $3,856.41 |