- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,187.76 / $2,187.76
| Facility | | $1,412.54 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,290.87 / $2,511.89
| Professional | | $2,041.74 | $2,290.87 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,754.23
| Facility | | $2,187.76 | $2,187.76 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,548.13 / $3,548.13
| Facility | | $34.67 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $3,801.89 / $11,481.54
| Professional | | $1,737.80 | $3,801.89 | $11,481.54 |
- 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
- $1,778.28 / $2,511.89 / $3,715.35
| Professional | | $1,778.28 | $2,511.89 | $3,715.35 |