- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,389.56 / $1,389.56 / $1,389.56
| Facility | | $1,389.56 | $1,389.56 | $1,389.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $485.19 / $910.40 / $1,389.56
| Professional | | $485.19 | $910.40 | $1,389.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.28 / $1,327.03 / $1,407.57
| Facility | | $1,216.28 | $1,327.03 | $1,407.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.18 / $1,317.18 / $1,317.18
| Professional | | $1,317.18 | $1,317.18 | $1,317.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $941.33 / $941.33 / $941.33
| Facility | | $941.33 | $941.33 | $941.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.17 / $941.33 / $2,443.59
| Professional | | $687.17 | $941.33 | $2,443.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $485.19 / $1,352.37 / $7,852.81
| Facility | | $485.19 | $1,352.37 | $7,852.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.04 / $837.16 / $2,143.80
| Professional | | $501.04 | $837.16 | $2,143.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.04 / $834.37 / $1,121.23
| Professional | | $501.04 | $834.37 | $1,121.23 |