- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,412.54
| Facility | | $1,318.26 | $1,318.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,479.11 / $2,187.76
| Professional | | $1,258.93 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,737.80
| Facility | | $1,412.54 | $1,412.54 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $2,238.72 / $2,238.72
| Facility | | $34.67 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,905.46 / $8,128.31
| Professional | | $1,174.90 | $1,905.46 | $8,128.31 |
- 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
- $1,071.52 / $1,513.56 / $2,238.72
| Professional | | $1,071.52 | $1,513.56 | $2,238.72 |