- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.78 / $1,394.78 / $1,394.78
| Professional | | $1,394.78 | $1,394.78 | $1,394.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,449.18 / $1,564.46 / $1,646.80
| Professional | | $1,449.18 | $1,564.46 | $1,646.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $799.37 / $799.37 / $1,640.86
| Facility | | $799.37 | $799.37 | $1,640.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $799.37 / $1,571.55 / $2,456.25
| Professional | | $799.37 | $1,571.55 | $2,456.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,394.78 / $1,696.20 / $8,901.35
| Facility | | $1,394.78 | $1,696.20 | $8,901.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.28 / $1,078.93 / $2,157.06
| Professional | | $641.28 | $1,078.93 | $2,157.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.25 / $186.69 / $352.00
| Facility | | $185.25 | $186.69 | $352.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.69 / $230.16 / $441.27
| Professional | | $186.69 | $230.16 | $441.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $792.07 / $1,078.93 / $2,003.18
| Professional | | $792.07 | $1,078.93 | $2,003.18 |