- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $2,570.40
| Facility | | $1,202.26 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,202.26 / $1,949.84
| Professional | | $1,096.48 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,584.89
| Facility | | $1,288.25 | $1,288.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $2,089.30 / $2,089.30
| Facility | | $34.67 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $7,585.78
| Professional | | $1,148.15 | $1,819.70 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,466.84 / $4,466.84 / $20,417.38
| Facility | | $4,466.84 | $4,466.84 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,380.38 / $1,949.84
| Professional | | $933.25 | $1,380.38 | $1,949.84 |