- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $1,698.24
| Facility | | $1,412.54 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,819.70 / $3,388.44
| Professional | | $1,584.89 | $1,819.70 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $2,290.87
| Facility | | $1,905.46 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,090.30 / $3,090.30
| Facility | | $34.67 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,511.89 / $11,220.18
| Professional | | $1,737.80 | $2,511.89 | $11,220.18 |
- 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 / $2,041.74 / $3,162.28
| Professional | | $1,479.11 | $2,041.74 | $3,162.28 |