- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,584.89 / $2,454.71
| Professional | | $1,096.48 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $1,949.84 / $3,630.78
| Professional | | $245.47 | $1,949.84 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $186.21 / $229.09
| Professional | | $104.71 | $186.21 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $3,235.94 / $3,311.31
| Professional | | $3,090.30 | $3,235.94 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $323.59 / $1,862.09
| Professional | | $213.80 | $323.59 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $870.96 / $1,995.26
| Facility | | $144.54 | $870.96 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.25 / $1,258.93 / $2,398.83
| Professional | | $776.25 | $1,258.93 | $2,398.83 |