- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $3,630.78 / $4,570.88
| Facility | | $3,235.94 | $3,630.78 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,630.78 / $4,677.35
| Professional | | $2,630.27 | $3,630.78 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $9,332.54
| Facility | | $275.42 | $275.42 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $3,162.28 / $5,128.61
| Professional | | $2,137.96 | $3,162.28 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $4,570.88
| Facility | | $2,187.76 | $2,187.76 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,187.76 / $7,943.28
| Professional | | $1,862.09 | $2,187.76 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $562.34 / $3,235.94
| Facility | | $257.04 | $562.34 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,344.23 / $4,073.80
| Professional | | $1,548.82 | $2,344.23 | $4,073.80 |