- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,981.07 / $3,981.07 / $3,981.07
| Facility | | $3,981.07 | $3,981.07 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $549.54 / $707.95
| Professional | | $436.52 | $549.54 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.86 / $812.83 / $1,698.24
| Professional | | $512.86 | $812.83 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $724.44 / $1,318.26
| Facility | | $512.86 | $724.44 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $549.54 / $1,148.15
| Professional | | $60.26 | $549.54 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $2,238.72 / $2,754.23
| Professional | | $1,096.48 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $776.25 / $1,230.27
| Facility | | $512.86 | $776.25 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.26 / $549.54 / $1,698.24
| Professional | | $60.26 | $549.54 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $812.83 / $1,905.46
| Professional | | $309.03 | $812.83 | $1,905.46 |