- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $7,413.10 / $17,782.79
| Facility | | $4,786.30 | $7,413.10 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,890.45 / $4,570.88
| Professional | | $3,162.28 | $3,890.45 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $14,454.40
| Facility | | $4,786.30 | $4,786.30 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $6,165.95
| Professional | | $3,801.89 | $3,801.89 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $69,183.10 / $104,712.85
| Facility | | $4,677.35 | $69,183.10 | $104,712.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,888.44 / $14,454.40
| Professional | | $5,011.87 | $5,888.44 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $4,786.30
| Professional | | $1,995.26 | $2,884.03 | $4,786.30 |