- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,479.11 / $1,479.11
| Facility | | $1,412.54 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,548.82 / $2,511.89
| Professional | | $1,318.26 | $1,548.82 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,905.46
| Facility | | $1,513.56 | $1,513.56 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $2,454.71 / $2,454.71
| Facility | | $34.67 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,949.84 / $7,762.47
| Professional | | $1,202.26 | $1,949.84 | $7,762.47 |
- 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
- $1,148.15 / $1,584.89 / $2,511.89
| Professional | | $1,148.15 | $1,584.89 | $2,511.89 |