- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,309.57 / $7,943.28
| Facility | | $4,265.80 | $6,309.57 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $6,165.95 / $8,317.64
| Professional | | $4,265.80 | $6,165.95 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $19,952.62
| Facility | | $446.68 | $446.68 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,677.35 / $10,232.93
| Professional | | $3,090.30 | $4,677.35 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $7,585.78 / $7,585.78
| Facility | | $5,370.32 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $7,585.78 / $15,848.93
| Professional | | $912.01 | $7,585.78 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,122.02 / $5,754.40
| Facility | | $346.74 | $1,122.02 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,630.78 / $5,888.44
| Professional | | $2,398.83 | $3,630.78 | $5,888.44 |