- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,652.75 / $3,669.81 / $4,202.10
| Facility | | $1,652.75 | $3,669.81 | $4,202.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,652.75 / $1,816.03 / $16,172.60
| Professional | | $1,652.75 | $1,816.03 | $16,172.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,536.46 / $4,536.46 / $4,536.46
| Facility | | $4,536.46 | $4,536.46 | $4,536.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,855.99 / $4,536.46 / $4,672.55
| Professional | | $3,855.99 | $4,536.46 | $4,672.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,633.10 / $4,246.93 / $5,521.02
| Professional | | $2,633.10 | $4,246.93 | $5,521.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,235.06 / $4,072.26 / $6,108.40
| Professional | | $3,235.06 | $4,072.26 | $6,108.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,311.54 / $2,560.09 / $3,672.77
| Professional | | $2,311.54 | $2,560.09 | $3,672.77 |