- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,801.89 / $5,754.40
| Facility | | $2,754.23 | $3,801.89 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $4,897.79
| Professional | | $2,630.27 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $11,748.98
| Facility | | $354.81 | $354.81 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $4,677.35 / $6,456.54
| Professional | | $3,311.31 | $4,677.35 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $6,309.57
| Facility | | $3,467.37 | $3,467.37 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,467.37 / $9,120.11
| Professional | | $2,951.21 | $3,467.37 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $2,344.23 / $4,570.88
| Facility | | $281.84 | $2,344.23 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $3,162.28 / $5,248.07
| Professional | | $2,187.76 | $3,162.28 | $5,248.07 |