- 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
- $3,715.35 / $4,466.84 / $6,918.31
| Professional | | $3,715.35 | $4,466.84 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $5,011.87 / $7,079.46
| Professional | | $2,691.53 | $5,011.87 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $4,570.88 / $6,918.31
| Facility | | $1,096.48 | $4,570.88 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $4,786.30 / $31,622.78
| Professional | | $3,715.35 | $4,786.30 | $31,622.78 |
- 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
- $3,388.44 / $4,365.16 / $6,606.93
| Professional | | $3,388.44 | $4,365.16 | $6,606.93 |