- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,897.79 / $6,025.60
| Facility | | $4,265.80 | $4,897.79 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,897.79 / $6,456.54
| Professional | | $3,467.37 | $4,897.79 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $13,803.84
| Facility | | $575.44 | $575.44 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,365.16 / $7,585.78
| Professional | | $3,235.94 | $4,365.16 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $5,495.41 / $5,495.41
| Facility | | $5,370.32 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $5,495.41 / $10,715.19
| Professional | | $645.65 | $5,495.41 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $758.58 / $4,786.30
| Facility | | $346.74 | $758.58 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,090.30 / $5,370.32
| Professional | | $2,187.76 | $3,090.30 | $5,370.32 |