- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $7,762.47
| Facility | | $4,786.30 | $4,786.30 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $4,677.35
| Professional | | $2,630.27 | $3,630.78 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,495.41 / $16,595.87
| Facility | | $4,677.35 | $5,495.41 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $3,801.89
| Professional | | $1,905.46 | $2,884.03 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,964.78 / $10,964.78 / $10,964.78
| Facility | | $10,964.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,786.30 / $4,786.30 / $5,754.40
| Professional | | $4,786.30 | $4,786.30 | $5,754.40 |
- 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
- $2,630.27 / $3,715.35 / $4,677.35
| Professional | | $2,630.27 | $3,715.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,786.30 / $7,244.36
| Professional | | $2,884.03 | $4,786.30 | $7,244.36 |