- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,874.42 / $2,874.42 / $2,874.42
| Facility | | $2,874.42 | $2,874.42 | $2,874.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.21 / $1,056.28 / $1,197.26
| Professional | | $800.21 | $1,056.28 | $1,197.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.35 / $1,284.22 / $1,837.91
| Professional | | $992.35 | $1,284.22 | $1,837.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,200.33 / $1,388.78 / $2,130.46
| Professional | | $1,200.33 | $1,388.78 | $2,130.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,874.42 / $2,874.42 / $2,874.42
| Facility | | $2,874.42 | $2,874.42 | $2,874.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.21 / $1,048.01 / $1,197.26
| Professional | | $800.21 | $1,048.01 | $1,197.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.80 / $1,243.17 / $1,867.71
| Professional | | $902.80 | $1,243.17 | $1,867.71 |