- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,897.79 / $4,897.79
| Facility | | $4,265.80 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,548.13 / $5,495.41
| Professional | | $2,818.38 | $3,548.13 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $2,951.21
| Facility | | $1,380.38 | $1,380.38 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,079.46 / $10,232.93
| Professional | | $4,265.80 | $7,079.46 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,073.80 / $5,754.40
| Professional | | $2,884.03 | $4,073.80 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,897.79 / $10,232.93
| Facility | | $4,265.80 | $4,897.79 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,890.45 / $6,025.60
| Professional | | $3,235.94 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,466.84 / $5,011.87
| Professional | | $2,951.21 | $4,466.84 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,698.24 / $3,890.45 / $6,025.60
| Facility | | $1,698.24 | $3,890.45 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,981.07 / $5,370.32
| Professional | | $3,235.94 | $3,981.07 | $5,370.32 |