- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,995.26 / $1,995.26
| Facility | | $1,412.54 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,137.96 / $3,981.07
| Professional | | $1,862.09 | $2,137.96 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,691.53
| Facility | | $2,238.72 | $2,238.72 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- 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
- $2,041.74 / $2,951.21 / $12,589.25
| Professional | | $2,041.74 | $2,951.21 | $12,589.25 |
- 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
- $1,698.24 / $2,344.23 / $3,715.35
| Professional | | $1,698.24 | $2,344.23 | $3,715.35 |