- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,107.14 / $1,107.14 / $1,107.14
| Facility | | $1,107.14 | $1,107.14 | $1,107.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.57 / $874.57 / $1,107.14
| Professional | | $874.57 | $874.57 | $1,107.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,568.45 / $1,854.46 / $1,878.26
| Professional | | $1,568.45 | $1,854.46 | $1,878.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,620.00 / $1,636.20 / $2,057.40
| Professional | | $1,620.00 | $1,636.20 | $2,057.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.66 / $1,150.86 / $6,756.10
| Facility | | $111.66 | $1,150.86 | $6,756.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $666.46 / $930.84 / $1,396.26
| Professional | | $666.46 | $930.84 | $1,396.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.23 / $964.28 / $1,396.26
| Professional | | $508.23 | $964.28 | $1,396.26 |