- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,380.94 / $2,380.94 / $2,380.94
| Facility | | $2,380.94 | $2,380.94 | $2,380.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,161.94 / $2,380.94 / $2,635.27
| Professional | | $2,161.94 | $2,380.94 | $2,635.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,339.10 / $2,339.10 / $4,514.46
| Facility | | $2,339.10 | $2,339.10 | $4,514.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.50 / $2,339.10 / $3,087.61
| Professional | | $1,728.50 | $2,339.10 | $3,087.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.76 / $404.08 / $610.74
| Facility | | $281.76 | $404.08 | $610.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.15 / $404.08 / $500.29
| Professional | | $250.15 | $404.08 | $500.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $2,837.98 / $3,353.16
| Professional | | $287.76 | $2,837.98 | $3,353.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,142.31 / $1,559.25 / $2,209.15
| Professional | | $1,142.31 | $1,559.25 | $2,209.15 |