- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,715.35 / $4,786.30
| Professional | | $3,090.30 | $3,715.35 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $1,862.09 / $2,187.76
| Professional | | $416.87 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $457.09 / $707.95
| Facility | | $407.38 | $457.09 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,090.30 / $7,585.78
| Professional | | $2,754.23 | $3,090.30 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $2,187.76 / $6,456.54
| Facility | | $346.74 | $2,187.76 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,862.09 / $1,862.09
| Professional | | $79.43 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $3,715.35
| Facility | | $354.81 | $354.81 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,715.35
| Professional | | $1,862.09 | $2,290.87 | $3,715.35 |