- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,238.72 / $3,467.37
| Professional | | $2,041.74 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,890.45 / $4,570.88 / $4,677.35
| Professional | | $3,890.45 | $4,570.88 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,981.07 / $4,073.80 / $5,128.61
| Professional | | $3,981.07 | $4,073.80 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $2,691.53 / $2,818.38
| Facility | | $173.78 | $2,691.53 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $954.99 / $1,148.15 / $2,290.87
| Professional | | $954.99 | $1,148.15 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $1,778.28
| Facility | | $199.53 | $199.53 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $1,148.15 / $2,344.23
| Professional | | $426.58 | $1,148.15 | $2,344.23 |