- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,454.71 / $2,951.21
| Facility | | $2,041.74 | $2,454.71 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,454.71 / $3,162.28
| Professional | | $1,698.24 | $2,454.71 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $6,165.95
| Facility | | $218.78 | $218.78 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,630.27 / $3,630.78
| Professional | | $1,584.89 | $2,630.27 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,238.72 / $3,019.95
| Facility | | $2,238.72 | $2,238.72 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,238.72 / $5,011.87
| Professional | | $1,905.46 | $2,238.72 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $389.05 / $2,187.76
| Facility | | $177.83 | $389.05 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,584.89 / $2,818.38
| Professional | | $1,071.52 | $1,584.89 | $2,818.38 |