- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,055.57 / $5,055.57 / $5,055.57
| Facility | | $5,055.57 | $5,055.57 | $5,055.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,380.35 / $5,055.57 / $6,407.53
| Professional | | $3,380.35 | $5,055.57 | $6,407.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $4,382.14
| Facility | | $3,282.89 | $3,282.89 | $4,382.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $3,381.38
| Professional | | $456.28 | $3,282.89 | $3,381.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,229.67 / $3,574.95 / $5,805.40
| Facility | | $2,229.67 | $3,574.95 | $5,805.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.02 / $580.54 / $586.34
| Professional | | $557.02 | $580.54 | $586.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.49 / $437.58 / $4,192.65
| Professional | | $251.49 | $437.58 | $4,192.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,667.28 / $2,889.56 / $4,543.79
| Professional | | $2,667.28 | $2,889.56 | $4,543.79 |