- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,146.42 / $1,146.42 / $1,146.42
| Facility | | $1,146.42 | $1,146.42 | $1,146.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $729.97 / $1,133.68 / $1,146.42
| Professional | | $729.97 | $1,133.68 | $1,146.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.80 / $1,136.80 / $1,136.80
| Professional | | $1,136.80 | $1,136.80 | $1,136.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $881.10 / $881.10 / $881.10
| Facility | | $881.10 | $881.10 | $881.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.87 / $881.10 / $1,620.00
| Professional | | $109.87 | $881.10 | $1,620.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.02 / $734.78 / $1,265.25
| Professional | | $551.02 | $734.78 | $1,265.25 |