- 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
- $3,890.45 / $8,511.38 / $10,471.29
| Professional | | $3,890.45 | $8,511.38 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $5,011.87 / $5,011.87
| Facility | | $4,466.84 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $5,011.87 / $14,791.08
| Professional | | $4,265.80 | $5,011.87 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $389.05 / $1,047.13 / $4,570.88
| Facility | | $389.05 | $1,047.13 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,467.37 / $5,754.40
| Professional | | $2,398.83 | $3,467.37 | $5,754.40 |