- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $2,691.53 / $2,754.23
| Professional | | $1,698.24 | $2,691.53 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $380.19 / $776.25
| Facility | | $316.23 | $380.19 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $2,818.38 / $5,128.61
| Professional | | $288.40 | $2,818.38 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $2,691.53 / $2,884.03
| Facility | | $275.42 | $2,691.53 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $147.91 / $1,047.13 / $2,137.96
| Facility | | $147.91 | $1,047.13 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,513.56 / $2,238.72
| Professional | | $1,071.52 | $1,513.56 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,238.72 / $19,054.61 / $19,054.61
| Facility | | $2,238.72 | $19,054.61 | $19,054.61 |