- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,165.95 / $7,413.10
| Facility | | $3,890.45 | $6,165.95 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $6,025.60 / $7,943.28
| Professional | | $3,890.45 | $6,025.60 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $676.08 / $19,054.61
| Facility | | $676.08 | $676.08 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,011.87 / $9,772.37
| Professional | | $2,630.27 | $5,011.87 | $9,772.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $4,365.16 / $5,495.41
| Facility | | $776.25 | $4,365.16 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $4,365.16 / $14,791.08
| Professional | | $776.25 | $4,365.16 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,047.13 / $4,570.88
| Facility | | $316.23 | $1,047.13 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,235.94 / $5,623.41
| Professional | | $2,238.72 | $3,235.94 | $5,623.41 |