- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,023.66 / $4,346.52 / $4,661.47
| Facility | | $3,023.66 | $4,346.52 | $4,661.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,947.82 / $4,346.52 / $4,661.47
| Professional | | $2,947.82 | $4,346.52 | $4,661.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,086.50 / $4,428.68 / $6,104.22
| Professional | | $4,086.50 | $4,428.68 | $6,104.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.50 / $422.50 / $3,681.54
| Facility | | $422.50 | $422.50 | $3,681.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $4,550.34 / $4,550.34
| Professional | | $422.50 | $4,550.34 | $4,550.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.05 / $3,164.26 / $29,293.49
| Facility | | $524.05 | $3,164.26 | $29,293.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,393.83 / $3,111.97 / $5,662.39
| Professional | | $2,393.83 | $3,111.97 | $5,662.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,393.83 / $3,011.18 / $5,712.82
| Professional | | $2,393.83 | $3,011.18 | $5,712.82 |