- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,388.44 / $4,073.80
| Facility | | $2,884.03 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,388.44 / $4,365.16
| Professional | | $2,398.83 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $8,511.38
| Facility | | $257.04 | $257.04 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,951.21 / $4,677.35
| Professional | | $1,995.26 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $4,265.80
| Facility | | $2,691.53 | $2,691.53 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,691.53 / $7,244.36
| Professional | | $2,290.87 | $2,691.53 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $512.86 / $3,162.28
| Facility | | $234.42 | $512.86 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,137.96 / $3,801.89
| Professional | | $1,479.11 | $2,137.96 | $3,801.89 |