- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,577.48 / $1,577.48 / $1,577.48
| Facility | | $1,577.48 | $1,577.48 | $1,577.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.82 / $1,424.82 / $1,577.48
| Professional | | $1,424.82 | $1,424.82 | $1,577.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.41 / $686.49 / $858.12
| Professional | | $550.41 | $686.49 | $858.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.25 / $2,040.77 / $2,665.94
| Facility | | $132.25 | $2,040.77 | $2,665.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.69 / $1,599.97 / $3,125.45
| Professional | | $668.69 | $1,599.97 | $3,125.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.42 / $519.84 / $2,934.79
| Facility | | $111.42 | $519.84 | $2,934.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.41 / $550.41 / $3,339.26
| Professional | | $117.41 | $550.41 | $3,339.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.62 / $306.62 / $306.62
| Professional | | $306.62 | $306.62 | $306.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,265.08 / $1,927.34 / $3,125.45
| Professional | | $1,265.08 | $1,927.34 | $3,125.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,769.10 / $3,257.70 / $3,257.70
| Professional | | $2,769.10 | $3,257.70 | $3,257.70 |