- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,467.37 / $3,890.45
| Facility | | $3,090.30 | $3,467.37 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,090.30 / $3,090.30
| Professional | | $2,511.89 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,073.80 / $7,585.78 / $12,589.25
| Facility | | $4,073.80 | $7,585.78 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $3,090.30 / $3,548.13
| Professional | | $3,019.95 | $3,090.30 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,801.89 / $4,365.16
| Professional | | $2,290.87 | $3,801.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,019.95 / $3,548.13
| Professional | | $2,398.83 | $3,019.95 | $3,548.13 |