- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,691.53 / $3,162.28
| Facility | | $2,041.74 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $2,691.53 / $3,388.44
| Professional | | $1,819.70 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $6,309.57
| Facility | | $177.83 | $177.83 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,089.30 / $3,890.45
| Professional | | $1,737.80 | $2,089.30 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $3,235.94
| Facility | | $2,290.87 | $2,290.87 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,290.87 / $5,011.87
| Professional | | $1,949.84 | $2,290.87 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $467.74 / $2,398.83
| Facility | | $204.17 | $467.74 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,819.70 / $3,235.94
| Professional | | $1,148.15 | $1,819.70 | $3,235.94 |