- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $891.25 / $8,709.64
| Professional | | $173.78 | $891.25 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,570.40 / $6,456.54
| Facility | | $1,445.44 | $2,570.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $2,630.27
| Professional | | $1,737.80 | $1,819.70 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $2,570.40 / $3,981.07
| Facility | | $478.63 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.56 / $2,238.72 / $4,265.80
| Facility | | $602.56 | $2,238.72 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $131.83
| Professional | | $131.83 | $131.83 | $131.83 |