- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,888.44 / $9,332.54
| Facility | | $4,570.88 | $5,888.44 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $5,888.44 / $7,762.47
| Professional | | $3,981.07 | $5,888.44 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $18,197.01
| Facility | | $588.84 | $588.84 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,495.41 / $7,762.47 / $10,232.93
| Professional | | $5,495.41 | $7,762.47 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $9,772.37
| Facility | | $5,888.44 | $5,888.44 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,888.44 / $14,125.38
| Professional | | $5,011.87 | $5,888.44 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $3,801.89 / $7,413.10
| Facility | | $446.68 | $3,801.89 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,128.61 / $8,511.38
| Professional | | $3,630.78 | $5,128.61 | $8,511.38 |