- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,187.76 / $2,187.76
| Facility | | $1,412.54 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,187.76 / $3,548.13
| Professional | | $1,995.26 | $2,187.76 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $3,162.28
| Facility | | $2,454.71 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $3,981.07 / $3,981.07
| Facility | | $34.67 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,089.30 / $3,235.94 / $12,882.50
| Professional | | $2,089.30 | $3,235.94 | $12,882.50 |
- 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
- $1,862.09 / $2,454.71 / $3,715.35
| Professional | | $1,862.09 | $2,454.71 | $3,715.35 |