- 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 / $3,090.30
| Professional | | $1,698.24 | $2,454.71 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $213.80 / $213.80 / $6,309.57
| Facility | | $213.80 | $213.80 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,089.30 / $3,467.37
| Professional | | $1,380.38 | $2,089.30 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $2,570.40 / $2,691.53
| Facility | | $2,570.40 | $2,570.40 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,570.40 / $5,011.87
| Professional | | $2,187.76 | $2,570.40 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $380.19 / $2,187.76
| Facility | | $173.78 | $380.19 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,548.82 / $2,754.23
| Professional | | $1,071.52 | $1,548.82 | $2,754.23 |