- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,890.45 / $3,890.45
| Facility | | $1,412.54 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,548.13 / $3,890.45 / $6,456.54
| Professional | | $3,548.13 | $3,890.45 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $5,623.41
| Facility | | $4,466.84 | $4,466.84 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Professional | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $7,079.46 / $7,079.46
| Facility | | $34.67 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $5,623.41 / $19,952.62
| Professional | | $3,801.89 | $5,623.41 | $19,952.62 |
- 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
- $3,090.30 / $3,890.45 / $6,760.83
| Professional | | $3,090.30 | $3,890.45 | $6,760.83 |