- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,818.38 / $2,818.38
| Facility | | $1,412.54 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,951.21 / $3,311.31
| Professional | | $2,754.23 | $2,951.21 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,548.13
| Facility | | $2,818.38 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $4,570.88 / $4,570.88
| Facility | | $34.67 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $4,265.80 / $13,182.57
| Professional | | $2,238.72 | $4,265.80 | $13,182.57 |
- 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
- $2,137.96 / $2,884.03 / $4,365.16
| Professional | | $2,137.96 | $2,884.03 | $4,365.16 |