- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,897.79
| Facility | | $2,041.74 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $758.58 / $1,047.13
| Professional | | $295.12 | $758.58 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $2,041.74 / $4,897.79
| Facility | | $812.83 | $2,041.74 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $691.83 / $2,951.21
| Professional | | $436.52 | $691.83 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $1,202.26 / $2,041.74
| Facility | | $302.00 | $1,202.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $524.81 / $741.31
| Professional | | $398.11 | $524.81 | $741.31 |