- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,344.23 / $2,344.23
| Facility | | $1,412.54 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,398.83 / $2,691.53
| Professional | | $2,187.76 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,884.03
| Facility | | $2,290.87 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,570.40
| Professional | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,630.78 / $3,630.78
| Facility | | $34.67 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,548.13 / $13,803.84
| Professional | | $1,819.70 | $3,548.13 | $13,803.84 |
- 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
- $1,862.09 / $2,630.27 / $3,981.07
| Professional | | $1,862.09 | $2,630.27 | $3,981.07 |