- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $3,388.44 / $4,073.80
| Facility | | $2,951.21 | $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
- $398.11 / $398.11 / $9,120.11
| Facility | | $398.11 | $398.11 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,951.21 / $5,011.87
| Professional | | $2,187.76 | $2,951.21 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $3,630.78 / $7,079.46
| Professional | | $436.52 | $3,630.78 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $501.19 / $3,311.31
| Facility | | $234.42 | $501.19 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,089.30 / $3,890.45
| Professional | | $1,479.11 | $2,089.30 | $3,890.45 |