- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,584.89 / $2,511.89
| Facility | | $1,258.93 | $1,584.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,584.89 / $2,089.30
| Professional | | $1,122.02 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $4,897.79
| Facility | | $144.54 | $144.54 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,041.74 / $3,090.30
| Professional | | $1,445.44 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $2,290.87
| Facility | | $2,238.72 | $2,238.72 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $3,801.89
| Professional | | $1,905.46 | $2,238.72 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.65 / $912.01 / $1,905.46
| Facility | | $109.65 | $912.01 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $1,318.26 / $2,238.72
| Professional | | $912.01 | $1,318.26 | $2,238.72 |