- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,027.25 / $1,027.25 / $1,027.25
| Facility | | $1,027.25 | $1,027.25 | $1,027.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.68 / $707.68 / $1,027.25
| Professional | | $707.68 | $707.68 | $1,027.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,739.79 / $3,206.18 / $3,261.60
| Professional | | $2,739.79 | $3,206.18 | $3,261.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,234.50 / $1,246.84 / $1,567.82
| Professional | | $1,234.50 | $1,246.84 | $1,567.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.68 / $1,027.96 / $5,757.82
| Facility | | $707.68 | $1,027.96 | $5,757.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.73 / $821.79 / $1,222.95
| Professional | | $583.73 | $821.79 | $1,222.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $433.14 / $821.79 / $1,388.94
| Professional | | $433.14 | $821.79 | $1,388.94 |