- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.04 / $1,246.60 / $1,271.05
| Facility | | $117.04 | $1,246.60 | $1,271.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.60 / $1,271.05 / $2,183.64
| Professional | | $1,246.60 | $1,271.05 | $2,183.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,748.02 / $2,640.47 / $2,640.47
| Professional | | $1,748.02 | $2,640.47 | $2,640.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,373.71 / $2,373.71 / $2,373.71
| Facility | | $2,373.71 | $2,373.71 | $2,373.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,017.65 / $2,017.65 / $2,373.71
| Professional | | $2,017.65 | $2,017.65 | $2,373.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,912.85 / $13,967.65 / $14,660.64
| Facility | | $4,912.85 | $13,967.65 | $14,660.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,721.15 / $15,721.15 / $24,564.30
| Professional | | $15,721.15 | $15,721.15 | $24,564.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.78 / $1,463.67 / $2,007.74
| Professional | | $975.78 | $1,463.67 | $2,007.74 |