- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $3,019.95 / $3,019.95
| Facility | | $1,412.54 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,019.95 / $9,120.11
| Professional | | $2,754.23 | $3,019.95 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,388.44 / $3,388.44 / $4,365.16
| Facility | | $3,388.44 | $3,388.44 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $3,890.45 / $3,890.45
| Professional | | $3,890.45 | $3,890.45 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $5,495.41 / $5,495.41
| Facility | | $34.67 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,466.84 / $17,782.79
| Professional | | $2,884.03 | $4,466.84 | $17,782.79 |
- 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
- $2,511.89 / $3,388.44 / $5,128.61
| Professional | | $2,511.89 | $3,388.44 | $5,128.61 |