- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $3,548.13
| Facility | | $1,995.26 | $2,691.53 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,570.40 / $3,467.37
| Professional | | $1,862.09 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $8,511.38
| Facility | | $288.40 | $288.40 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,691.53 / $4,570.88
| Professional | | $1,513.56 | $2,691.53 | $4,570.88 |
- 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 / $6,606.93
| Professional | | $1,905.46 | $2,238.72 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $724.44 / $2,290.87
| Facility | | $158.49 | $724.44 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,548.82 / $2,884.03
| Professional | | $1,096.48 | $1,548.82 | $2,884.03 |