- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,219.35 / $2,219.35 / $2,219.35
| Facility | | $2,219.35 | $2,219.35 | $2,219.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $950.61 / $1,545.12 / $2,472.17
| Professional | | $950.61 | $1,545.12 | $2,472.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,029.70 / $3,305.54 / $3,506.17
| Facility | | $3,029.70 | $3,305.54 | $3,506.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,281.02 / $3,281.02 / $3,281.02
| Professional | | $3,281.02 | $3,281.02 | $3,281.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,253.75 / $2,253.75 / $2,253.75
| Facility | | $2,253.75 | $2,253.75 | $2,253.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,915.69 / $2,253.75 / $5,702.81
| Professional | | $1,915.69 | $2,253.75 | $5,702.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $950.61 / $2,378.69 / $15,333.41
| Facility | | $950.61 | $2,378.69 | $15,333.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.65 / $1,689.97 / $3,770.74
| Professional | | $981.65 | $1,689.97 | $3,770.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.65 / $1,472.48 / $2,269.04
| Professional | | $981.65 | $1,472.48 | $2,269.04 |