- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,737.80 / $1,737.80
| Facility | | $1,412.54 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,454.71
| Professional | | $1,479.11 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $2,454.71
| Facility | | $1,949.84 | $1,949.84 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Professional | | $2,187.76 | $2,187.76 | $2,187.76 |
- 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
- $1,548.82 / $2,511.89 / $10,232.93
| Professional | | $1,548.82 | $2,511.89 | $10,232.93 |
- 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
- $1,380.38 / $1,862.09 / $2,951.21
| Professional | | $1,380.38 | $1,862.09 | $2,951.21 |