- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,760.63 / $1,760.63 / $1,760.63
| Facility | | $1,760.63 | $1,760.63 | $1,760.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.98 / $1,784.10 / $2,111.53
| Professional | | $1,431.98 | $1,784.10 | $2,111.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,762.74 / $2,350.32 / $2,829.96
| Professional | | $1,762.74 | $2,350.32 | $2,829.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,414.26 / $1,414.26 / $1,414.26
| Facility | | $1,414.26 | $1,414.26 | $1,414.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.28 / $1,414.26 / $1,760.73
| Professional | | $213.28 | $1,414.26 | $1,760.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,310.51 / $12,643.10 / $13,104.06
| Facility | | $2,310.51 | $12,643.10 | $13,104.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.12 / $1,618.81 / $2,076.98
| Professional | | $937.12 | $1,618.81 | $2,076.98 |