- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,943.21 / $1,943.21 / $4,129.32
| Facility | | $1,943.21 | $1,943.21 | $4,129.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.50 / $607.50 / $607.50
| Professional | | $607.50 | $607.50 | $607.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $777.28 / $777.28 / $1,263.08
| Professional | | $777.28 | $777.28 | $1,263.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,943.21 / $1,943.21 / $1,962.64
| Professional | | $1,943.21 | $1,943.21 | $1,962.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,943.21 / $1,943.21 / $3,148.00
| Facility | | $1,943.21 | $1,943.21 | $3,148.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.50 / $607.50 / $1,943.21
| Professional | | $607.50 | $607.50 | $1,943.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.04 / $1,165.93 / $3,400.62
| Professional | | $991.04 | $1,165.93 | $3,400.62 |