- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,370.53 / $2,370.53 / $2,370.53
| Facility | | $2,370.53 | $2,370.53 | $2,370.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.30 / $1,768.80 / $2,370.53
| Professional | | $1,473.30 | $1,768.80 | $2,370.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.19 / $335.97 / $2,149.26
| Facility | | $159.19 | $335.97 | $2,149.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.19 / $171.45 / $2,314.59
| Professional | | $159.19 | $171.45 | $2,314.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,685.49 / $3,685.49 / $6,144.70
| Facility | | $3,685.49 | $3,685.49 | $6,144.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $3,685.49 / $8,352.10
| Professional | | $192.51 | $3,685.49 | $8,352.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.47 / $556.10 / $2,599.80
| Professional | | $179.47 | $556.10 | $2,599.80 |