- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,786.30 / $14,454.40
| Facility | | $3,548.13 | $4,786.30 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,715.35 / $5,495.41
| Professional | | $3,235.94 | $3,715.35 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $12,882.50
| Facility | | $3,090.30 | $3,090.30 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $6,918.31
| Professional | | $5,888.44 | $5,888.44 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $4,786.30 / $8,317.64
| Facility | | $3,548.13 | $4,786.30 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $17,782.79
| Professional | | $1,995.26 | $1,995.26 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,786.30 / $5,754.40
| Facility | | $1,995.26 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $3,162.28
| Professional | | $1,995.26 | $1,995.26 | $3,162.28 |