- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,563.46 / $2,563.46 / $2,563.46
| Professional | | $2,563.46 | $2,563.46 | $2,563.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,660.32 / $2,871.94 / $3,023.09
| Professional | | $2,660.32 | $2,871.94 | $3,023.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $2,560.64
| Facility | | $1,406.76 | $1,406.76 | $2,560.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,406.76 / $2,504.90 / $4,026.76
| Professional | | $1,406.76 | $2,504.90 | $4,026.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.57 / $2,563.46 / $13,890.95
| Facility | | $309.57 | $2,563.46 | $13,890.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.64 / $1,184.33 / $2,062.92
| Professional | | $744.64 | $1,184.33 | $2,062.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $339.53 / $340.53 / $650.75
| Facility | | $339.53 | $340.53 | $650.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.53 / $425.51 / $804.88
| Professional | | $340.53 | $425.51 | $804.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $744.64 / $1,184.33 / $2,022.97
| Professional | | $744.64 | $1,184.33 | $2,022.97 |