- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,902.82 / $2,902.82 / $2,902.82
| Facility | | $2,902.82 | $2,902.82 | $2,902.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,695.11 / $2,902.82 / $2,902.82
| Professional | | $1,695.11 | $2,902.82 | $2,902.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $606.74 / $3,666.80 / $3,996.81
| Professional | | $606.74 | $3,666.80 | $3,996.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,811.11 / $3,005.99 / $24,998.62
| Facility | | $1,811.11 | $3,005.99 | $24,998.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.36 / $696.23 / $1,799.40
| Professional | | $399.36 | $696.23 | $1,799.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.25 / $549.13 / $1,012.96
| Professional | | $474.25 | $549.13 | $1,012.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $448.43 / $2,176.30 / $9,610.75
| Professional | | $448.43 | $2,176.30 | $9,610.75 |