- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,454.71 / $2,454.71
| Facility | | $1,412.54 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,570.40 / $2,884.03
| Professional | | $2,344.23 | $2,570.40 | $2,884.03 |
- 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
- $1,949.84 / $3,630.78 / $21,877.62
| Professional | | $1,949.84 | $3,630.78 | $21,877.62 |
- 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
- $1,949.84 / $2,691.53 / $4,168.69
| Professional | | $1,949.84 | $2,691.53 | $4,168.69 |