- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,520.00 / $1,520.00 / $1,520.00
| Facility | | $1,520.00 | $1,520.00 | $1,520.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.57 / $1,195.34 / $1,494.19
| Professional | | $977.57 | $1,195.34 | $1,494.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,772.97 / $3,772.97 / $3,772.97
| Professional | | $3,772.97 | $3,772.97 | $3,772.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $961.55 / $961.55 / $1,470.00
| Facility | | $961.55 | $961.55 | $1,470.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $961.55 / $1,085.81 / $1,344.00
| Professional | | $961.55 | $1,085.81 | $1,344.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.30 / $880.74 / $1,074.56
| Professional | | $651.30 | $880.74 | $1,074.56 |