- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,317.25 / $2,317.25 / $2,317.25
| Facility | | $2,317.25 | $2,317.25 | $2,317.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,690.21 / $2,317.25 / $2,638.10
| Professional | | $1,690.21 | $2,317.25 | $2,638.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.46 / $2,583.84 / $3,278.89
| Professional | | $2,161.46 | $2,583.84 | $3,278.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $221.56 / $411.48 / $3,481.71
| Facility | | $221.56 | $411.48 | $3,481.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.74 / $379.82 / $3,418.41
| Professional | | $205.74 | $379.82 | $3,418.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,416.31 / $2,416.31 / $2,416.31
| Facility | | $2,416.31 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.99 / $2,416.31 / $2,416.31
| Professional | | $257.99 | $2,416.31 | $2,416.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $819.07 / $1,237.56 / $2,375.33
| Professional | | $819.07 | $1,237.56 | $2,375.33 |