- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $2,454.71 / $2,454.71
| Facility | | $1,412.54 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,570.40 / $4,073.80
| Professional | | $2,238.72 | $2,570.40 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,818.38 / $2,818.38 / $3,548.13
| Facility | | $2,818.38 | $2,818.38 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $4,466.84 / $4,466.84
| Facility | | $34.67 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $4,168.69 / $14,454.40
| Professional | | $2,398.83 | $4,168.69 | $14,454.40 |
- 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
- $1,949.84 / $2,884.03 / $4,168.69
| Professional | | $1,949.84 | $2,884.03 | $4,168.69 |