- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $4,677.35 / $6,165.95
| Facility | | $3,630.78 | $4,677.35 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,786.30 / $6,165.95
| Professional | | $3,467.37 | $4,786.30 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $15,135.61
| Facility | | $346.74 | $346.74 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $3,890.45 / $7,762.47
| Professional | | $2,630.27 | $3,890.45 | $7,762.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,623.41 / $5,623.41
| Facility | | $5,128.61 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,623.41 / $11,748.98
| Professional | | $4,168.69 | $5,623.41 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $831.76 / $4,168.69
| Facility | | $295.12 | $831.76 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,884.03 / $4,677.35
| Professional | | $1,862.09 | $2,884.03 | $4,677.35 |