- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $3,162.28 / $3,162.28
| Facility | | $1,621.81 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,162.28 / $3,548.13
| Professional | | $2,454.71 | $3,162.28 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $1,819.70
| Professional | | $1,148.15 | $1,445.44 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.33 / $3,890.45 / $5,248.07
| Facility | | $102.33 | $3,890.45 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $1,479.11 / $3,090.30
| Professional | | $741.31 | $1,479.11 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,348.96 / $1,348.96
| Professional | | $933.25 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $933.25 / $933.25
| Professional | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,479.11 / $3,090.30
| Professional | | $812.83 | $1,479.11 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,623.41 / $6,606.93 / $6,606.93
| Professional | | $5,623.41 | $6,606.93 | $6,606.93 |