- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,862.09 / $1,862.09
| Facility | | $1,412.54 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,949.84 / $2,137.96
| Professional | | $1,737.80 | $1,949.84 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,862.09 / $1,862.09 / $2,344.23
| Facility | | $1,862.09 | $1,862.09 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $2,951.21 / $2,951.21
| Facility | | $34.67 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,951.21 / $9,549.93
| Professional | | $1,479.11 | $2,951.21 | $9,549.93 |
- 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 / $3,235.94
| Professional | | $1,513.56 | $2,187.76 | $3,235.94 |