- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $4,365.16 / $4,365.16
| Facility | | $1,412.54 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,365.16 / $7,079.46
| Professional | | $3,981.07 | $4,365.16 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,897.79 / $4,897.79 / $6,309.57
| Facility | | $4,897.79 | $4,897.79 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $5,623.41 / $5,623.41
| Professional | | $5,623.41 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $7,943.28 / $7,943.28
| Facility | | $34.67 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,168.69 / $6,456.54 / $21,877.62
| Professional | | $4,168.69 | $6,456.54 | $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
- $3,311.31 / $4,570.88 / $7,413.10
| Professional | | $3,311.31 | $4,570.88 | $7,413.10 |