- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,890.45 / $6,606.93
| Facility | | $1,288.25 | $3,890.45 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,890.45 / $5,623.41
| Professional | | $3,019.95 | $3,890.45 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,128.61 / $5,888.44
| Professional | | $3,630.78 | $5,128.61 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $3,090.30 / $6,309.57
| Facility | | $346.74 | $3,090.30 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,168.69 / $24,547.09
| Professional | | $3,019.95 | $4,168.69 | $24,547.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,949.84 / $6,165.95
| Facility | | $346.74 | $1,949.84 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,890.45 / $5,888.44
| Professional | | $2,951.21 | $3,890.45 | $5,888.44 |