- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,801.89 / $12,022.64
| Facility | | $3,090.30 | $3,801.89 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,162.28 / $3,388.44
| Professional | | $3,090.30 | $3,162.28 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,890.45 / $7,585.78
| Facility | | $2,884.03 | $3,890.45 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,311.31 / $4,786.30
| Professional | | $3,090.30 | $3,311.31 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $3,235.94 / $3,801.89
| Facility | | $1,230.27 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,235.94
| Professional | | $3,235.94 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,949.84 / $3,801.89
| Facility | | $1,862.09 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,235.94 / $3,801.89
| Professional | | $3,235.94 | $3,235.94 | $3,801.89 |