- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,070.24 / $1,070.24 / $1,070.24
| Facility | | $1,070.24 | $1,070.24 | $1,070.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $680.62 / $1,070.24 / $1,636.74
| Professional | | $680.62 | $1,070.24 | $1,636.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,140.48 / $2,405.04 / $4,366.58
| Facility | | $2,140.48 | $2,405.04 | $4,366.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.06 / $979.06 / $1,057.38
| Professional | | $979.06 | $979.06 | $1,057.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,018.60 / $1,018.60 / $1,018.60
| Facility | | $1,018.60 | $1,018.60 | $1,018.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.58 / $743.58 / $2,056.13
| Professional | | $743.58 | $743.58 | $2,056.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $525.02 / $1,070.24 / $2,675.60
| Facility | | $525.02 | $1,070.24 | $2,675.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.02 / $525.02 / $525.02
| Professional | | $525.02 | $525.02 | $525.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,562.55 / $2,675.60 / $4,238.14
| Professional | | $1,562.55 | $2,675.60 | $4,238.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.91 / $813.25 / $1,253.19
| Professional | | $751.91 | $813.25 | $1,253.19 |