- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $4,897.79 / $4,897.79
| Facility | | $562.34 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,023.29 / $2,089.30
| Professional | | $537.03 | $1,023.29 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,951.21 / $3,090.30
| Professional | | $2,818.38 | $2,951.21 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,897.79 / $5,495.41
| Facility | | $1,995.26 | $4,897.79 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $1,949.84 / $2,570.40
| Professional | | $562.34 | $1,949.84 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,511.89 / $4,897.79 / $8,511.38
| Facility | | $2,511.89 | $4,897.79 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,238.72 / $2,951.21
| Professional | | $1,096.48 | $2,238.72 | $2,951.21 |