- 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
- $3,388.44 / $3,890.45 / $6,025.60
| Professional | | $3,388.44 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,128.61 / $6,606.93
| Professional | | $3,630.78 | $5,128.61 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $4,786.30 / $6,456.54
| Professional | | $2,454.71 | $4,786.30 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,148.15 / $3,981.07 / $7,079.46
| Facility | | $1,148.15 | $3,981.07 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,365.16 / $26,915.35
| Professional | | $3,388.44 | $4,365.16 | $26,915.35 |
- 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
- $3,162.28 / $4,168.69 / $6,309.57
| Professional | | $3,162.28 | $4,168.69 | $6,309.57 |