- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $3,715.35 / $4,073.80
| Facility | | $181.97 | $3,715.35 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $4,073.80
| Professional | | $3,715.35 | $3,715.35 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,570.88 / $10,715.19
| Facility | | $3,715.35 | $4,570.88 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $3,715.35 / $5,128.61
| Professional | | $125.89 | $3,715.35 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,715.35 / $5,623.41
| Facility | | $3,467.37 | $3,715.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,715.35 / $3,801.89
| Professional | | $3,548.13 | $3,715.35 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,890.45 / $5,754.40
| Facility | | $2,951.21 | $3,890.45 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $2,754.23 / $2,951.21
| Professional | | $125.89 | $2,754.23 | $2,951.21 |