- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,344.23 / $3,019.95
| Facility | | $1,412.54 | $2,344.23 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,290.87 / $3,715.35
| Professional | | $1,995.26 | $2,290.87 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,162.28
| Facility | | $2,454.71 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,981.07 / $3,981.07
| Facility | | $34.67 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,467.37 / $10,964.78
| Professional | | $2,041.74 | $3,467.37 | $10,964.78 |
- 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
- $1,548.82 / $2,187.76 / $3,715.35
| Professional | | $1,548.82 | $2,187.76 | $3,715.35 |