- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,305.01 / $2,305.01 / $2,305.01
| Facility | | $2,305.01 | $2,305.01 | $2,305.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,816.17 / $2,305.01 / $3,442.59
| Professional | | $1,816.17 | $2,305.01 | $3,442.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,994.16
| Facility | | $1,406.76 | $1,406.76 | $1,994.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $1,448.96
| Professional | | $218.80 | $1,406.76 | $1,448.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $847.52 / $1,795.46 / $2,563.46
| Facility | | $847.52 | $1,795.46 | $2,563.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.08 / $294.08 / $309.57
| Professional | | $294.08 | $294.08 | $309.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.32 / $228.46 / $1,673.28
| Professional | | $167.32 | $228.46 | $1,673.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.78 / $1,302.91 / $2,215.73
| Professional | | $1,213.78 | $1,302.91 | $2,215.73 |