- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,786.30 / $4,786.30
| Facility | | $2,570.40 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $2,570.40 / $2,951.21
| Professional | | $478.63 | $2,570.40 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,801.89 / $3,801.89 / $3,801.89
| Professional | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,011.87 / $9,549.93
| Facility | | $2,630.27 | $5,011.87 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,135.61 / $15,135.61 / $15,135.61
| Professional | | $15,135.61 | $15,135.61 | $15,135.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,412.54 / $3,981.07
| Professional | | $1,318.26 | $1,412.54 | $3,981.07 |