- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,456.54 / $7,762.47
| Facility | | $3,981.07 | $6,456.54 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $6,309.57 / $8,317.64
| Professional | | $3,981.07 | $6,309.57 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $691.83 / $691.83 / $19,952.62
| Facility | | $691.83 | $691.83 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,248.07 / $10,232.93
| Professional | | $3,311.31 | $5,248.07 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,606.93 / $6,606.93
| Facility | | $5,128.61 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $6,606.93 / $15,488.17
| Professional | | $794.33 | $6,606.93 | $15,488.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.59 / $1,096.48 / $4,677.35
| Facility | | $323.59 | $1,096.48 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $3,388.44 / $5,888.44
| Professional | | $2,344.23 | $3,388.44 | $5,888.44 |