- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,570.40 / $2,570.40
| Facility | | $1,412.54 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,691.53 / $3,019.95
| Professional | | $2,454.71 | $2,691.53 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $3,235.94
| Facility | | $2,570.40 | $2,570.40 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $2,884.03 / $2,884.03
| Professional | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $4,168.69 / $4,168.69
| Facility | | $34.67 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,801.89 / $12,022.64
| Professional | | $2,041.74 | $3,801.89 | $12,022.64 |
- 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
- $1,659.59 / $2,290.87 / $3,981.07
| Professional | | $1,659.59 | $2,290.87 | $3,981.07 |