- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,691.53 / $2,691.53
| Facility | | $1,412.54 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,691.53 / $4,365.16
| Professional | | $2,454.71 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $3,548.13
| Facility | | $2,884.03 | $2,884.03 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $4,677.35 / $4,677.35
| Facility | | $34.67 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,981.07 / $17,378.01
| Professional | | $2,398.83 | $3,981.07 | $17,378.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $48,977.88
| Facility | | $8,511.38 | $8,511.38 | $48,977.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,754.23 / $4,265.80
| Professional | | $1,995.26 | $2,754.23 | $4,265.80 |