- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $4,073.80 / $5,248.07
| Facility | | $2,951.21 | $4,073.80 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,981.07 / $5,248.07
| Professional | | $2,570.40 | $3,981.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $380.19 / $12,589.25
| Facility | | $380.19 | $380.19 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,370.32 / $6,918.31
| Professional | | $3,388.44 | $5,370.32 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $6,309.57
| Facility | | $2,884.03 | $2,884.03 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,884.03 / $9,772.37
| Professional | | $2,454.71 | $2,884.03 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $1,995.26 / $3,801.89
| Facility | | $263.03 | $1,995.26 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,884.03 / $4,786.30
| Professional | | $1,995.26 | $2,884.03 | $4,786.30 |