- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,281.44 / $1,281.44 / $1,281.44
| Facility | | $1,281.44 | $1,281.44 | $1,281.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.72 / $909.72 / $1,281.44
| Professional | | $909.72 | $909.72 | $1,281.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.56 / $2,353.98 / $2,394.67
| Professional | | $2,011.56 | $2,353.98 | $2,394.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.75 / $1,776.34 / $2,233.61
| Professional | | $1,758.75 | $1,776.34 | $2,233.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $92.46 / $1,281.44 / $7,903.07
| Facility | | $92.46 | $1,281.44 | $7,903.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $594.23 / $864.75 / $1,244.00
| Professional | | $594.23 | $864.75 | $1,244.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.14 / $1,184.76 / $1,244.00
| Professional | | $494.14 | $1,184.76 | $1,244.00 |