- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,884.03 / $3,981.07
| Professional | | $1,621.81 | $2,884.03 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $7,762.47
| Professional | | $251.19 | $251.19 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $812.83 / $5,370.32
| Professional | | $371.54 | $812.83 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $1,479.11 / $4,073.80
| Facility | | $346.74 | $1,479.11 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $2,398.83 / $2,398.83
| Professional | | $446.68 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $363.08 / $3,548.13
| Facility | | $204.17 | $363.08 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $257.04 / $2,089.30
| Professional | | $208.93 | $257.04 | $2,089.30 |