- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,739.49 / $2,739.49 / $2,739.49
| Facility | | $2,739.49 | $2,739.49 | $2,739.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,885.57 / $2,739.49 / $3,118.80
| Professional | | $1,885.57 | $2,739.49 | $3,118.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,230.86 / $2,230.86 / $3,686.40
| Professional | | $2,230.86 | $2,230.86 | $3,686.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $284.83 / $459.06 / $3,884.31
| Facility | | $284.83 | $459.06 | $3,884.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.53 / $423.74 / $3,813.69
| Professional | | $229.53 | $423.74 | $3,813.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $2,446.40
| Facility | | $2,446.40 | $2,446.40 | $2,446.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $3,210.83
| Professional | | $286.94 | $2,446.40 | $3,210.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.17 / $1,463.60 / $3,145.73
| Professional | | $957.17 | $1,463.60 | $3,145.73 |