- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,041.74 / $2,041.74
| Facility | | $1,412.54 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,137.96 / $2,398.83
| Professional | | $1,905.46 | $2,137.96 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,570.40
| Facility | | $2,041.74 | $2,041.74 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,311.31 / $3,311.31
| Facility | | $34.67 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,951.21 / $17,782.79
| Professional | | $1,621.81 | $2,951.21 | $17,782.79 |
- 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
- $1,513.56 / $2,187.76 / $3,467.37
| Professional | | $1,513.56 | $2,187.76 | $3,467.37 |