- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,995.14 / $2,995.14 / $2,995.14
| Facility | | $2,995.14 | $2,995.14 | $2,995.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,545.87 / $2,995.14
| Professional | | $2,396.11 | $2,545.87 | $2,995.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.63 / $392.29 / $490.36
| Professional | | $356.63 | $392.29 | $490.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $351.72 / $3,426.44 / $5,391.26
| Facility | | $351.72 | $3,426.44 | $5,391.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,778.52 / $11,381.53
| Professional | | $2,495.94 | $2,778.52 | $11,381.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.58 / $376.57 / $508.30
| Facility | | $275.58 | $376.57 | $508.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.02 / $360.38 / $745.94
| Professional | | $302.02 | $360.38 | $745.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,495.94 / $2,778.52
| Professional | | $2,495.94 | $2,495.94 | $2,778.52 |