- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,118.52 / $2,118.52 / $2,118.52
| Facility | | $2,118.52 | $2,118.52 | $2,118.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.47 / $2,781.79 / $2,845.95
| Professional | | $1,752.47 | $2,781.79 | $2,845.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.47 / $434.67 / $1,878.39
| Facility | | $382.47 | $434.67 | $1,878.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.59 / $455.61 / $718.15
| Professional | | $360.59 | $455.61 | $718.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $393.04 / $2,092.67 / $2,944.48
| Facility | | $393.04 | $2,092.67 | $2,944.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.16 / $1,429.51 / $6,869.73
| Professional | | $520.16 | $1,429.51 | $6,869.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.97 / $2,395.17 / $2,395.17
| Facility | | $1,366.97 | $2,395.17 | $2,395.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.51 / $1,513.60 / $2,690.85
| Professional | | $557.51 | $1,513.60 | $2,690.85 |