- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,084.21 / $2,084.21 / $2,084.21
| Facility | | $2,084.21 | $2,084.21 | $2,084.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,084.21 / $2,354.80 / $2,605.28
| Professional | | $2,084.21 | $2,354.80 | $2,605.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.37 / $347.37 / $504.74
| Professional | | $347.37 | $347.37 | $504.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,095.19 / $2,095.19 / $3,360.51
| Facility | | $2,095.19 | $2,095.19 | $3,360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $3,637.50
| Professional | | $192.51 | $1,472.88 | $3,637.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.88 / $2,188.42 / $9,481.87
| Facility | | $249.88 | $2,188.42 | $9,481.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.80 / $403.79 / $4,381.05
| Professional | | $108.80 | $403.79 | $4,381.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.25 / $381.98 / $4,088.98
| Professional | | $123.25 | $381.98 | $4,088.98 |