- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,621.81 / $1,621.81
| Facility | | $1,412.54 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,621.81 / $2,630.27
| Professional | | $1,479.11 | $1,621.81 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.70 / $1,819.70 / $2,344.23
| Facility | | $1,819.70 | $1,819.70 | $2,344.23 |
- 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 / $2,951.21 / $2,951.21
| Facility | | $34.67 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,398.83 / $8,511.38
| Professional | | $1,548.82 | $2,398.83 | $8,511.38 |
- 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
- $1,318.26 / $1,698.24 / $2,754.23
| Professional | | $1,318.26 | $1,698.24 | $2,754.23 |