- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,981.07 / $4,786.30
| Facility | | $3,548.13 | $3,981.07 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $3,981.07 / $5,248.07
| Professional | | $2,884.03 | $3,981.07 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $10,964.78
| Facility | | $478.63 | $478.63 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,467.37 / $6,025.60
| Professional | | $2,570.40 | $3,467.37 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,365.16
| Facility | | $4,265.80 | $4,265.80 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $4,265.80 / $8,511.38
| Professional | | $512.86 | $4,265.80 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $602.56 / $3,890.45
| Facility | | $275.42 | $602.56 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,511.89 / $4,365.16
| Professional | | $1,778.28 | $2,511.89 | $4,365.16 |