- 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 / $3,311.31
| Professional | | $1,737.80 | $1,949.84 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $1,995.26 / $2,398.83
| Facility | | $1,995.26 | $1,995.26 | $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 / $3,162.28 / $3,162.28
| Facility | | $34.67 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,570.40 / $10,471.29
| Professional | | $1,513.56 | $2,570.40 | $10,471.29 |
- 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
- $1,479.11 / $2,089.30 / $3,162.28
| Professional | | $1,479.11 | $2,089.30 | $3,162.28 |