- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,888.44 / $5,888.44 / $5,888.44
| Facility | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $562.34 / $1,348.96
| Professional | | $467.74 | $562.34 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,584.89 / $1,905.46
| Professional | | $1,047.13 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $977.24 / $1,548.82
| Professional | | $645.65 | $977.24 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,380.38 / $5,370.32
| Facility | | $1,288.25 | $1,380.38 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $933.25 / $1,905.46
| Professional | | $549.54 | $933.25 | $1,905.46 |