- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,754.40 / $6,918.31
| Facility | | $3,630.78 | $5,754.40 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,630.78 / $5,623.41 / $7,413.10
| Professional | | $3,630.78 | $5,623.41 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $17,782.79
| Facility | | $630.96 | $630.96 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,677.35 / $9,120.11
| Professional | | $2,630.27 | $4,677.35 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $5,128.61
| Facility | | $3,981.07 | $3,981.07 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,981.07 / $13,803.84
| Professional | | $3,388.44 | $3,981.07 | $13,803.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.12 / $977.24 / $4,265.80
| Facility | | $295.12 | $977.24 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,019.95 / $5,248.07
| Professional | | $2,089.30 | $3,019.95 | $5,248.07 |