- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,344.23 / $2,344.23
| Facility | | $1,412.54 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,570.40 / $3,801.89
| Professional | | $2,238.72 | $2,570.40 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,090.30
| Facility | | $2,454.71 | $2,454.71 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- 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
- $2,089.30 / $3,235.94 / $10,715.19
| Professional | | $2,089.30 | $3,235.94 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,238.72 / $3,715.35
| Professional | | $1,584.89 | $2,238.72 | $3,715.35 |