- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,481.62 / $2,481.62 / $2,481.62
| Facility | | $2,481.62 | $2,481.62 | $2,481.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,481.62 / $2,887.71 / $3,890.21
| Professional | | $2,481.62 | $2,887.71 | $3,890.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $389.53 / $6,431.55
| Professional | | $248.35 | $389.53 | $6,431.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.89 / $696.72 / $4,319.39
| Professional | | $270.89 | $696.72 | $4,319.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $349.07 / $1,463.85 / $3,890.21
| Facility | | $349.07 | $1,463.85 | $3,890.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.35 / $389.53 / $626.64
| Professional | | $248.35 | $389.53 | $626.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.65 / $241.11 / $2,271.23
| Professional | | $209.65 | $241.11 | $2,271.23 |