- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $676.08 / $812.83 / $1,230.27
| Professional | | $676.08 | $812.83 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $977.24
| Facility | | $812.83 | $812.83 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $812.83 / $1,445.44
| Professional | | $93.33 | $812.83 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $891.25 / $4,897.79
| Facility | | $676.08 | $891.25 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $562.34 / $1,096.48
| Professional | | $338.84 | $562.34 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.43 / $446.68 / $794.33
| Facility | | $79.43 | $446.68 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $562.34 / $1,047.13
| Professional | | $338.84 | $562.34 | $1,047.13 |