- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,905.46 / $1,905.46
| Facility | | $1,412.54 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,041.74 / $2,290.87
| Professional | | $1,862.09 | $2,041.74 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,398.83
| Facility | | $1,905.46 | $1,905.46 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,090.30 / $3,090.30
| Facility | | $34.67 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,884.03 / $12,302.69
| Professional | | $1,513.56 | $2,884.03 | $12,302.69 |
- 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 / $2,137.96 / $3,235.94
| Professional | | $1,513.56 | $2,137.96 | $3,235.94 |