- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,981.07 / $5,128.61
| Professional | | $2,818.38 | $3,981.07 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $575.44 / $575.44
| Professional | | $549.54 | $575.44 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $5,128.61
| Facility | | $426.58 | $426.58 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $4,570.88 / $6,760.83
| Professional | | $478.63 | $4,570.88 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $3,630.78 / $29,512.09
| Facility | | $575.44 | $3,630.78 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $5,623.41
| Professional | | $1,905.46 | $2,884.03 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.84 / $2,041.74 / $4,570.88
| Facility | | $281.84 | $2,041.74 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,884.03 / $5,623.41
| Professional | | $1,905.46 | $2,884.03 | $5,623.41 |