- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $2,951.21 / $3,548.13
| Facility | | $131.83 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $3,548.13
| Professional | | $2,951.21 | $2,951.21 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,951.21 / $3,090.30
| Professional | | $2,290.87 | $2,951.21 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,951.21 / $2,951.21
| Facility | | $2,818.38 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Professional | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $4,786.30
| Professional | | $2,951.21 | $2,951.21 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $2,818.38 / $2,951.21
| Professional | | $125.89 | $2,818.38 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $2,238.72
| Facility | | $1,412.54 | $1,412.54 | $2,238.72 |