- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $3,801.89 / $6,606.93
| Facility | | $1,288.25 | $3,801.89 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,715.35 / $6,025.60
| Professional | | $3,090.30 | $3,715.35 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $4,265.80 / $6,025.60
| Professional | | $2,290.87 | $4,265.80 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $3,981.07 / $6,165.95
| Facility | | $1,096.48 | $3,981.07 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,073.80 / $25,703.96
| Professional | | $3,090.30 | $4,073.80 | $25,703.96 |
- 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 / $3,715.35 / $5,495.41
| Professional | | $2,951.21 | $3,715.35 | $5,495.41 |