- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,995.26 / $2,691.53 / $4,168.69
| Professional | | $1,995.26 | $2,691.53 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,570.88 / $5,370.32 / $5,623.41
| Professional | | $4,570.88 | $5,370.32 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,370.32 / $6,606.93
| Professional | | $5,248.07 | $5,370.32 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $2,951.21 / $20,417.38
| Facility | | $257.04 | $2,951.21 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,445.44 / $2,398.83
| Professional | | $1,148.15 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $1,905.46
| Facility | | $257.04 | $257.04 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $2,089.30 / $3,890.45
| Professional | | $1,148.15 | $2,089.30 | $3,890.45 |