- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $455.43 / $2,753.25 / $15,748.60
| Facility | | $455.43 | $2,753.25 | $15,748.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.43 / $455.43 / $2,285.19
| Professional | | $455.43 | $455.43 | $2,285.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.30 / $6,068.39 / $12,616.36
| Facility | | $2,691.30 | $6,068.39 | $12,616.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,890.91 / $3,606.76 / $5,016.42
| Professional | | $2,890.91 | $3,606.76 | $5,016.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,702.00 / $8,702.00 / $8,702.00
| Facility | | $8,702.00 | $8,702.00 | $8,702.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,514.29 / $1,514.29 / $2,753.00
| Facility | | $1,514.29 | $1,514.29 | $2,753.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.30 / $1,651.95 / $2,808.32
| Professional | | $1,101.30 | $1,651.95 | $2,808.32 |