- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,677.35 / $6,165.95 / $8,317.64
| Facility | | $4,677.35 | $6,165.95 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $6,606.93 / $8,511.38
| Professional | | $4,570.88 | $6,606.93 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $21,379.62
| Facility | | $478.63 | $478.63 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $5,128.61 / $10,964.78
| Professional | | $3,388.44 | $5,128.61 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $7,943.28 / $7,943.28
| Facility | | $5,888.44 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $7,943.28 / $16,218.10
| Professional | | $933.25 | $7,943.28 | $16,218.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $380.19 / $1,148.15 / $6,025.60
| Facility | | $380.19 | $1,148.15 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,511.89 / $3,801.89 / $6,760.83
| Professional | | $2,511.89 | $3,801.89 | $6,760.83 |